Across Britain, millions of patients, as well as their families and carers, are affected by chronic pain. Unfortunately, chronic pain can have a devastating impact upon a person's day-to-day life, work, hobbies and mental health and wellbeing.
Current approach to pain
Current thinking, developed over many years of turning routinely to pharmacological measures, presumes that pain should never be experienced in the modern world, and that there is a pill that can essentially resolve any type of pain.
This can, in a large part, be traced back to the development of the analgesic step ladder (or pain ladder) by the World Health Organization in 1986, and its inappropriate application to the management of non-cancer-related chronic pain, for which it was never validated (National Institute for Health and Care Excellence (NICE), 2017).
Importantly, NICE (2017) pointed out that:
‘using the WHO ladder in people with chronic pain, without taking into account the complexity of the person's individual needs, preferences for treatment, health priorities and lifestyle, may contribute to inappropriate prescribing.’
Why a shift is needed
Applying the WHO pain ladder to management of non-cancer-related chronic pain has been problematic, and the consequences include severe physical and mental side effects, drug misuse, dependence and withdrawal issues, and even drug poisoning (Ballantyne et al, 2016).
These adverse effects are not always taken seriously enough and weighed appropriately against the potential benefits of the drugs being considered. According to a report commissioned by Public Health England (PHE) (2019), for most people with non-cancer-related chronic pain, opioids cannot provide adequate clinical benefits when weighed against the risks of dependence, overdose poisoning and harms to others in the community. Further, NICE (2017) highlighted that it is unusual for chronic pain to be eliminated completely with an analgesic.
Barriers to change
Connelly (2020a) recently discovered under the Freedom of Information Act that referral-to-treatment times vary widely across Britain, with some patients waiting for more than 2 years to see a specialist pain management clinic to help them manage their symptoms after being referred by their GP.
Encouragingly, the clinics do offer a range of services for chronic pain beyond traditional pharmacological options such as opioid analgesics. For example, interventional procedures, physiotherapy, exercise programmes, psychological therapy and occupational therapy are all offered at pain management clinics (Connelly, 2020a). However, with some patients waiting so long to see a specialist, many have lost faith in the medical profession by the time they do, and many have deteriorated to an extent that, by the time they do see someone, their options are quite limited (Connelly, 2020b).
Conclusion
Patients living in the community with chronic pain require a holistic approach to their care, which may include some level of pharmacological management, but will also heavily rely on non-pharmacological approaches. According to NICE (2017):
‘Evidence suggests that non-pharmacological treatment may be effective in reducing symptoms and disability in some people with chronic pain and can also augment and complement analgesic use. Healthcare professionals who are responsible for helping people live with chronic pain should be familiar with the range of such non-pharmacological interventions—including physical and psychological therapies—and the local availability of these services.’
A shift is needed in the culture, whereby medical leaders, regulators and educators recognise the importance of non-pharmacological interventions in the prevention and management of disease and pain, taking them seriously enough to increase public investment in pain management programmes. More research must take place to begin to evidence the effectiveness of these interventions, and committed action is needed to help educate the public and reinforce patients' awareness regarding their own roles in the management of their health via these various interventions.