Pain is a big problem in New Zealand. It is going to get worse as the populations ages. Pain is the number one reason people will visit their GP. Many clinicians are not sure what needs treating and how best to treat it.
1. Pain is always real
Pain is a psychological event that is described in terms of actual or potential tissue damage. More importantly, pain is what the patient says it is—while expression of an individual’s pain is affected by their experience and a range of other associated factors, including specific context and affective state, pain is always real.1
Pain science and research, along with clinical and subjective experience, testify to the highly variable link between reported pain and actual tissue damage. There are often significant differences between patients’ pain reports and perceptions of their health providers.2 Despite this, patients continue to be characterised as ‘malingering’ or ‘attention seeking’, and pejorative pronouncements are made about drug seeking or illness behaviours. To query whether a particular patient’s pain is real is a nonsense. There are no objective tests for pain; it is a subjective experience, and its complexity can make assessment challenging, even when using accepted measures.3 Pain is ultimately all about what we experience: looking for a proximate stimulus to validate its cause may be redundant, and exacerbate the clinical situation.
2. Persistent pain and acute pain need to be treated differently
Most of our personal understanding of pain is based on useful, short-term (acute) pain. Pain in this situation has a purpose: alerting us to something harmful, or potentially harmful happening to our body. In persistent (chronic) pain, the experience rarely serves a purpose and becomes a problem in itself. There have been calls for persistent pain to be considered a disease in itself.4
Acute pain management involves treating the cause, and using analgesia to alleviate distress and promote function. A vital aspect of acute pain management is to prevent ongoing pain and disability. Persistent pain provides more challenges because the underlying mechanisms are not well understood, while the impact on daily life can be profound. Analgesic options do not always effectively treat persistent pain.5 Doubts about the validity of the pain (stigma), the effect of repeated treatment failures and (often) income loss mean that treatment is neither simple nor unidimensional.
It is important to look beyond the diagnosis to the person’s main concerns when providing persistent pain management. Treatments must address both pain intensity and the effects on participating in life; doing so improves quality of life and reduces costs in both economic and human terms.6
3. Persistent pain is extremely common and increasing
Persistent pain, defined as pain that persists for at least six months, is extremely common and affects 20.2% of the New Zealand population.7 The prevalence of persistent pain is rising in New Zealand and worldwide, at least in part because pain is more common in the elderly.7 Persistent pain causes the greatest loss of work productivity, accounts for 5% of all health loss and can affect all aspects of the person’s life. Depression, anxiety, poor quality and quantity of sleep, impaired movements, impaired concentration, social restrictions and relationship difficulties are common comorbidities of persistent pain.8 Poverty is a risk factor for persistent pain and also inversely predicts treatment outcomes.7,9 The cumulative effect of persistent pain can be brutal, with the severe persistent pain life bearing little resemblance to the pain-free state.
Recognition of the high prevalence of pain has led to calls to build treatment and prevention of persistent pain into health financing and policy.9 There are only two tertiary pain centres in New Zealand (Christchurch and Auckland) and this may not reflect need. Community level services are available for ACC patients but generally not available or funded by DHBs for people not receiving ACC. This means access to “better, sooner, and more convenient” pain management is scarce, particularly for people with limited personal resources. It also places an enormous burden on general practitioners, with flow-on effects throughout the health system, including emergency departments and in-patient admissions.
4. Biomedical treatment has limited effectiveness
Although pain is always real, discrete structural or pathoanatomical causes are often elusive or illusory. Imaging findings once thought to be diagnostic of the ‘source of the pain’ and used to guide interventional management have been found to be common in asymptomatic individuals.10 A biomedical approach that treats persistent pain by physical interventions has not reduced the burden of pain. Although surgery can be a valid treatment option for some people living with persistent pain (such as severe hip osteoarthritis), many surgical interventions often do not provide benefit to people with persistent pain commensurate with the high cost and high risk associated with these procedures. People who receive surgery for conditions associated with persistent pain frequently do not experience greater health gains than those who receive placebo procedures or well-structured conservative interventions.11 It is more appropriate to manage persistent musculoskeletal pain as a long-term health condition.12 High-value care for people with persistent pain includes developing shared understanding and an agreed management plan that comprises building autonomy and optimising physical activity, sleep, nutrition, stress and social participation.12 To reduce the growing burden of persistent pain on people, the healthcare system and society we need to focus on providing these high-value management approaches in favour of high cost but ultimately low-value interventions.
5. There are ethnicity and gender differences in perceptions and experience of pain
Persistent pain differentially affects ethnic groups in New Zealand. Pasifika and Asian populations are less likely to report pain than Europeans.6 Prevalence for Māori was complex, having a higher rate when sociodemographic factors were taken into account. However, Māori, Pasifika and Asian patients are underrepresented at persistent pain services, but report higher pain levels and disability.13 Culture plays an important role in the perception, experience and diagnosis of pain,14 and can be harnessed for better treatment delivery. For example, tinana (physical), hinengaro (psychological), wairua (spiritual) and whānau (family) support need to be incorporated in the treatment plan for best outcomes for Māori. In addition to cultural differences, we need to better understand whether Māori, Pasifika and Asian patients experience barriers to access and transition through services.
Population-based studies show higher prevalence of persistent pain in women, and many specific pain conditions are more common in women. Experimentally induced pain such as cold pressor tests show greater pain sensitivity and temporal summation in women.15 There is also some evidence which shows that healthcare providers are more likely to rate women as having less pain and be more likely to be exaggerating their pain.16 Women are more likely to be offered psychological support and men more likely to be offered analgesics.16
6. Pain education is lacking
Healthcare professionals need to have a modern understanding of pain for providing high value evidence-based treatments to people with acute and persistent pain. Research shows that clinicians generally demonstrate inadequate knowledge and inappropriate beliefs about pain.17 Insufficient pain-related competencies may limit how well healthcare professionals provide effective treatments. Research suggests that pain education in the health professional programmes is highly inadequate.18 It is thus a primary responsibility of universities providing health professional education to equip their graduates with knowledge and skills essential for effectively managing people experiencing pain. New Zealand has an excellent postgraduate programme for health professionals to upskill in pain management. This is offered by the Department of Orthopaedic Surgery & Musculoskeletal Medicine, University of Otago, Christchurch. The New Zealand Pain Society also supports health professionals in all areas of pain research and practice. There is an urgent need to investigate how pain is being taught (ie, nature, content and learning strategies) in the New Zealand health professional curricula.19 Such an investigation will help find ways to implement modernised pain education curricula including inter-professional education opportunities20 for collaboratively tackling persistent pain, a growing public health concern in New Zealand society.
In summary, pain is extremely common and increasing in prevalence in New Zealand. Pain is always real, acute and persistent pain need to be treated differently, and current biomedical treatment is often ineffective. There are differences in the way men and women experience pain, and in the experience of different ethnicities. Pain education for professionals is poor and more needs done to improve this. More research is needed in all of these areas to increase evidence-based ways of managing pain in the New Zealand population.