Realistic Medicine - Chronic Non-Malignant Pain Management
Background
- Chronic pain is defined as “pain that has been present for more than 12 weeks”. It is estimated that a third to a half of all adults in the UK experience chronic pain, with around 5% reporting severe chronic pain, significantly impacting their daily activities and quality of life.
- Pain symptoms are resistant to change with medical treatments. Concentrating on pharmacotherapy alone focuses on one of the least changeable aspects of the person’s long-term condition.
- By shifting the focus towards those areas which are more amenable to change, patients can begin to see how self-management can lead to real improvements in their quality of life.
Medication Review
An approach based on the mnemonic ‘SUGAR’ has been developed for use in pain reviews:
S: Social prescribing and self-management - Linking with local groups or activities helps to reduce social isolation, improve mood, increase physical activity and so improve quality of life. Link workers are an excellent contact for this, as is the Live Active Exercise referral scheme.
Useful resources to assist self-management approaches are My Live Well With Pain – Ten Footsteps Guide (one for people living with chronic pain and one for clinicians) and the Flippin Pain campaign.
U: Understanding pain and the patient - Discussing what chronic pain is helps people improve their understanding of chronic pain and how it can be managed. The Pain Cycle Tool on the Live Well With Pain website is a visual aid, which helps people to recognise how pain can affect different aspects of their lives, in both negative and self-reinforcing ways. The accompanying Self Care Cycle demonstrates the positive outcomes of adopting a range of self-management approaches to reverse or limit the impact of pain.
These resources are reassuring for patients and help them understand that chronic pain can exist without serious underlying cause, while still being a very real pain. Resources such as Brainman are very useful.
Communication and listening are key to finding out what is important to people and how chronic pain is affecting their daily life. The Brief Pain Inventory Scoring Tool is helpful.
G: Goal setting - Discussing and agreeing achievable realistic goals is important to engage people in their treatment and to help them assess their progress.
A: Acceptance – Assisting people to accept chronic pain as a long-term medical condition is key. It is important to emphasise that further investigations or surgeries may not be useful. Accepting that they can make changes to their lives to help manage their pain is important. This helps them to take control of their lives again. See Tamara Pincus video.
R: Relationship, reducing medication and review - Before attempting to reduce medication, it is important to build rapport and trust. The decision to reduce medication should be a joint one, with a plan for dose reduction agreed between clinician and patient. Regular review and support is essential. A useful resource is NHS GGC Chronic Non Malignant Pain Opioid Guidelines (currently being reviewed and will be updated this year).
Patient Story
Meet Christine
“Life completely changed for me after I sustained a fall, causing hand fracture. I am a 60-year-old retired nurse with 35 years of service. Initially my hand was strapped, put in a cast and I was referred to the Hand Specialist Physiotherapist. I was prescribed ibuprofen and co-codamol for the pain which was excruciating. I couldn’t care for myself.
After a series of excellent physio treatments via video call and painful steroid injections, I underwent surgery and was diagnosed with a complex regional pain syndrome (CRPS). I tried multiple therapies including desensitisation (brain retraining), mirror therapy, deep tissue laser therapy, transcutaneous electrical nerve stimulation and nerve study investigation. The charitable organisation Burning Nights CRPS has been an invaluable source of advice and support.
I was eventually referred for pharmacist-led pain review at my general practice, where I received patient-centred advice on medication, lifestyle and mindset to help with pain management. The pharmacist who does the reviews also teaches yoga online to people with chronic pain.
Although I still suffer from chronic pain and need help cutting up my food, dressing and other tasks, the pharmacist-led service has been invaluable, as it helped develop both my mental and physical coping mechanisms. Pain management is multifactorial. I have tried many therapies and learned about my condition and my body. This has enabled me to gain back my identity.”
Useful links
https://www.nhsggc.scot/hospitals-services/services-a-to-z/physical-activity/guidance-for-referral-and-signposting/
http://resources.livewellwithpain.co.uk/ten-footsteps/cover/
https://www.flippinpain.co.uk/
https://livewellwithpain.co.uk/wp-content/uploads/the-pain-cycle-2.pdf
https://www.youtube.com/watch?v=5KrUL8tOaQs
https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/05/Brief-Pain-Inventory.pdf
https://www.youtube.com/watch?v=ZUXPqphwp2U
Chronic Non Malignant Pain Opioid (nhsggc.org.uk)
Published: 13/05/2022. Medicines Update blogs are correct at the time of publishing.
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