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Managing patients with chronic pain

Dr Malcolm Hogg
Photo: Dr Malcolm Hogg
One in five Australians experience chronic non-cancer pain. A multidisciplinary approach is key to managing this common and complex condition, writes Karen Keast.


Chronic non-cancer pain, also known as persistent pain, is defined within the National Pain Strategy as constant daily pain that persists for a period of three months or more in the last six months.

The International Association for the Study of Pain (IASP) defines chronic pain as that persisting beyond normal tissue healing time, taken as three months in the absence of other criteria.

Australian studies show about 20 per cent of the population lives with chronic non-cancer pain, with a major subset, perhaps three to eight per cent of the population, experiencing a significant disabling pain.
Chronic pain can have a major effect on people’s lives, impacting on their day to day activities such as work, study, leisure activities, social and family life.

It’s unusual for chronic pain to be completely eliminated. Instead, the goal of treatment is to manage chronic pain, which can improve the patient’s physical and mental health as well as their quality of life.

While often a result of an injury or chronic conditions such as arthritis, chronic pain is distinct from acute pain and requires different approaches to treatment and management.

Dr Malcolm Hogg, Head of Pain Services at Melbourne Health, an immediate past president of the Australian Pain Society and board member of Painaustralia, says in many cases the original trigger for the pain may have resolved or settled but the pain remains due to changes in the central nervous system.

“The nerves in the peripheral tissues as well as where they connect at the spinal cord and subsequently integrated at the brain level can develop longer-term changes, which produces sensitisation and memory,” he says.

“The structural input causing the pain may resolve or is minimal but the pain remains due to ongoing activity of the pain system through the spinal cord and brain.”

Nurses and allied health practitioners have a major role to play in advocating for appropriate pain management for people living with chronic pain, including a comprehensive clinical assessment for pain and more effective pain treatment.

Specifically, of concern is the experience of patients suffering chronic pain in the acute health care setting, where new procedures may trigger heightened pain experiences but with inadequate system response.

A personalised assessment should include a general medical history, including a pain history, a physical examination, comprising neurological and musculoskeletal, and a psycho-social assessment. More extensive pain assessment may include diagnostic testing, specifically for bone inflammation and or nerve dysfunction, often ‘unseen’ markers of pathology contributing to musculoskeletal or neuropathic pain conditions.

Dr Hogg says it’s important to examine for the potential mechanisms of the pain, such as whether the pain is related to nerve injury, neural sensitisation, a structural cause such as arthritis, or a combination of mechanisms. In many chronic conditions, sensitisation becomes part of the persistent pain condition.

It’s also important to consider the impact of the pain on the person’s life, such as whether the person is psychologically distressed or physically deconditioned.

“Then find out how they are managing their pain,” he advises.

“A lot of patients are on moderate or high doses of medications, including opioids and anti-inflammatories, so this has implications for assessment and subsequent treatment recommendations, including optimal use of medications and limiting potential for adverse effects.

“For nursing and allied health practitioners, all these aspects should be considered when they then perform treatment or have clinical input.

“This should include the concept that the person may have a heightened pain experience to new procedures, such as placing IV cannula or having physio treatment, that they may not be as quick in responding to movements or have concerns about balance, and their understanding and concentration may not be as strong as other patients.

“Aspects of physical, mental and social functioning can be affected by chronic pain, such that care that patients receive may need to be modified and greater consideration of their needs shown.”

While there is no scientific method to measure pain or its severity, there are a range of easily accessible and standardised tools health practitioners can use for assessment, including the Brief Pain Inventory (BPI), a measure of neuropathic pain (DN4), and the Orebro musculoskeletal pain questionnaire.

More specific aspects of the pain experience, such as psychological distress, pain coping mechanisms and physical functioning can be individually assessed with a large number of specialised questionnaires, for example the Depression Anxiety Stress Scale (DASS-21) and the pain self-efficacy questionnaire, Human Activity Profile, to name a few.

Together with their GP or pain management team, the patient should be involved in developing a pain management plan that outlines realistic and relevant pain treatment goals and strategies. The plan, for example, may aim to reduce the severity of pain, reduce the use of medications and their potential side effects, and improve the patient’s physical activity and or reduce their anxiety and depression.

A person-centred, individualised and multidisciplinary approach that addresses the physical, psychological and social factors is paramount in managing chronic pain, Dr Hogg says.

“For many patients, where they are not disabled by pain, their pain is best managed through their GP - they can generally be managed with combination medications and physical activity,” he says.

“When things become more complicated and with a greater impact and subsequent disability, we require occupational therapy, clinical psychology input and, for some patients, interventions to try to reduce both pain severity and the impact of the pain on the person’s daily life.

“That leads us to interventions, which includes steroid and local anaesthetic injections and more complex techniques, such as neuromodulation and or multidisciplinary pain management programs, where targeted clinical psychology, physical activity and occupational therapy is combined in a coordinated approach.

“Interventions and pain management programs can go together in order to seek both pain reduction with lessened physical, psychological and social impact of the pain, with subsequent reduction in disability.”

While commonly used medications such as paracetamol, anti-inflammatory analgesics and opioids can work well in acute pain, they are less effective in addressing chronic pain.

Dr Hogg says medication such as anticonvulsants and antidepressants can be used in conjunction with the commonly used medications as part of a combination therapeutic approach to reduce non-cancer pain severity and sensitivity.

“Then, to reduce the physical, psycho-social impact, we need to follow this up with good education, clinical psychology input and physiotherapy input,” he says.

Dr Hogg says it’s important health practitioners and patients understand that the psycho-social features of chronic pain are not just aspects affecting their clinical presentation but are part of the pain experience and have a neurological basis.

“For example, a person who has had a trauma as a child or young adult has been demonstrated to have neural-sensitivity develop from that trauma, such that when they have a new experience of pain as an adult, they can have a heightened pain experience, including stronger brain response,” he says.

“We see this as someone who may not ‘cope well’ with us doing a minor procedure yet it may reflect a heightened neurological response as a reflection of their childhood or early adult trauma.

“Health practitioners who are not used to dealing with chronic pain patients can be dismissive of pain when, in fact, the patients are expressing their neurological experience of pain,” he says.

“It’s the patient’s experience of pain and we shouldn’t discount or ignore that experience. We need to acknowledge it.”



Want more?
A range of Australian websites provide health practitioner information and resources on chronic pain. Check out Painaustralia, Pain Health, the Pain Management Network and the National Prescribing Service.

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Karen Keast

Karen Keast is a freelance health journalist who writes news and feature articles for HealthTimes.

Karen regularly writes for some of Australia’s leading health news websites and magazines.  In a media career spanning 20 years, Karen has worked as a senior journalist in newspapers and television. She has covered the grind of daily news and worked as a politics reporter at countless state and federal elections.

Since venturing into freelance writing five years ago, Karen has found her niche in writing about the health sector for editors, businesses and corporations.

Karen has interviewed the heads of peak health organisations in Australia and overseas, and written hundreds of news and feature articles covering the dedicated work of health professionals who tread the corridors of hospitals and health services, universities, aged care facilities and practices, day in and day out.

Follow Karen Keast on Twitter @stylemywords