Why is unmanaged pain still a problem?

Pain, and, in particular, chronic pain, is older than medicine itself, and a major reason why people see doctors. It is central to human experience, and pervasive in clinical practice. However, pain — and patients in pain — are not well understood or managed. Our lack of understanding of pain mechanisms, the elusiveness of pain as a research subject, uncertainties in management, and deficiencies in giving patients empathic and integrated care erode doctors’ attempts to help meaningfully.

Pain management can be difficult. Von Baeyer (doi: 10.5694/mja12.10314) enunciates what we as practitioners know to be part of the reason: the measurement of pain is imperfect. Doctors like to be able to measure and quantify their findings to inform treatment. But there is no “ometer” for pain and, what is more, patients cope and react very differently. This makes treatment decisions even more challenging.

In the meantime, patients often are forced to soldier on. Having to wait 5 months in severe pain for access to a service where your pain might be adequately managed is intolerable. This is the median time it takes for Australian patients to gain access to a public pain clinic as reported in this issue by Hogg and colleagues (doi: 10.5694/mja12.10140). This statistic will not surprise many general practitioners, but it is to be hoped that putting it on the record will encourage an appropriate response by the government and the health system.

Drilling down on these long waiting times, Hogg and colleagues examined outpatient persistent pain management services in Australia and also found that the inequities in pain management are similar to those of our health system generally. Children and those living in rural areas were particularly poorly serviced, and privately funded care was much more readily available than care in a public setting.

In their editorial, Semple and Hogg (doi: 10.5694/mja12.10148) point out that long waiting times are a disincentive to the use of pain management services. This is a major problem for patients with chronic pain and, from their GPs’ perspective, it limits treatment options, making management of these patients stressful. None of us likes to feel impotent in any clinical context, let alone the emotive context of a patient in pain.

Semple and Hogg provide some guidance in this respect, describing successful models of pain management that have been developed in Australia in response to the problems of the current system.

A consequence of these problems is that a significant part of a primary care practitioner’s day is concerned with pain management. Harrison and colleagues (doi: 10.5694/mja12.10168) report the latest Australian general practice data on opioid prescribing. They found that, in 4.9% of general practice consultations, at least one opioid was prescribed or supplied — 60% of these were for musculoskeletal pain. Almost one in five GP consultations involve a patient with chronic pain (http://sydney.edu.au/medicine/fmrc/publications/sand-abstracts/150-Chronic_Pain.pdf).

It is only recently that pain and its consequences have been considered seriously in their own right. Cousins (doi: 10.5694/mja12.10181) laments the absence of data on the prevalence of and costs associated with chronic pain that have allowed the issue to be demoted as a health priority and as a disease.

Our approach to pain management reflects our expertise. Surgeons often choose to operate, anaesthetists to inject, psychiatrists to prescribe and counsel, and GPs, as well as treating, to try to help patients through the confusing maze of options, or the lack thereof. But we should all recognise pain as a significant health issue and strive to improve timely access to appropriate care.