The condition of pain is a universally-experienced phenomenon. With 20% of adults and 20-30% of children throughout the world with a chronic pain condition, it is ever-present, yet often overlooked. Pain is a costly condition, with an annual cost of nearly $19 billion for American children in medical evaluation, intervention, and lost productivity and a staggering $560 billion annual cost for both children and adults.
Just like the bumper sticker campaign to improve our awareness of motorcycles on the road, we need to improve our awareness and acknowledgement of those individuals at risk for or with pain. In this post, I will discuss some of the barriers to our awareness of pain and provide five insights as to how we all can start 'seeing' pain and addressing this condition in a more effective manner.
1- Pain is an emotional experience, not only for the patient but for the healthcare professionals that care for them. Coming face-to-face with those with pain is challenging and may remind us of our own personal difficulties with pain or pain of our loved ones. As professionals, we may feel helpless, that we may have nothing to offer medically if we feel ill-prepared to manage the complexities of the pain experience. Sometimes our efforts to comfort are misperceived by patients and this is a further source of distress to us, making us feel unskilled. Even though we may have dedicated our careers to helping others, we might need help ourselves in finding the right words and actions to support those in pain. We also need support from our colleagues to rally around each other and stand as a cohesive team when addressing pain management.
2- A reactive rather than proactive approach to pain. Institutions vary as to the resources that are dedicated to improvement of pain management. Leaders of some institutions may feel they are doing pretty well and don't need to put more effort into being intentional about pain management.
However, despite 'doing well' in the pain management arena (which is difficult to measure admittedly), there is always more to do. While we do need to assure we provide safe pain management, improvements can almost always be made that will not contribute to more risk. This is a common misconception given the history surrounding the opioid epidemic that working on pain management means increased risk, more opioids, more addiction.
Some leaders are not able to acknowledge the shortcomings of their institution's pain management practices and this unfortunately becomes part of the local culture. However, knowing what to expect after a surgical procedure, physical trauma or medical condition can put us in the position to take a proactive approach to pain and symptom management. And when we're better prepared, our communication is improved, with colleagues and with our patients. We feel more confident and competent.
If you fail to plan, you are planning to fail.
3- Lack of pain management training. An average of 16 hours is spent on pain management education throughout the four years of medical school. For comparison, veterinary students receive six times the duration of pain management education during pursuit of their professional degree. With little time and attention spent on pain management, the notion is promoted that pain management is not all that important, which couldn't be further from the truth. It silently sends a message to medical professionals that pain is no more than an interesting concept but not necessarily something the average physician or health care professional must work at on a daily basis. Along with the physiology of pain and pharmacologic interventions available, practical information needs to be ingrained in the culture so we can effectively identify, monitor, and prevent unnecessary pain and suffering.
4- Pain is a silent epidemic. Individuals rarely die as the direct result but pain is indirectly related to poorer quality of life, intense emotional distress, and lack of physical ability that makes life more difficult. Patients may undergo a multitude of medical evaluation with normal test results and are often shuttled from provider to provider to 'find the answer' to the cause of pain. As such, patients often feel misunderstood and invalidated when there may be no objective 'evidence' of their pain. They may feel alone, misunderstood by their friends and their families. Patients often describe that 'no one in my community understands chronic pain'. While a negative medical workup should be comforting, patients may continue to be fearful of what their pain means for their health and well-being and wonder if something has been missed, driving them to seek more medical evaluation. Often there is little time in a busy medical practices to understand the patient's experience of pain, which further drives patients into isolation. Those with pain are often recommended to home school, cut back on activities, further removing them from their important social supports and activities that bring them happiness or facilitate their development.
5- The 'I don't do pain management' attitude. The fact of the matter is that if you see patients face-to-face in any setting, you 'do' pain management. This brings me back to the reiteration of how we must integrate practical pain management education into medical schools and early training. If the expectation is made from the beginning of training, honing ones pain management skills becomes the norm rather than the need to 'cram' for management of a difficult pain management case. Or worse yet, not identifying, validating, or speaking of the pain condition at all.
Actionable Activities For Use Today
On pain being an emotional experience for all...
Be curious about your patient. Just because you initiate a conversation about pain with your patient does not imply that you can fix everything. And you do not need to. It is my belief that one is actually doing MORE damage when we do not acknowledge and validate the patient's experience of pain. If you do not ask about pain in a meaningful way, exploring how it affects daily life, the activities patients look forward to returning to, this can be perceived that you do not believe their pain is real.
On a proactive rather than a reactive approach...
Despite your institution's lack of robust resources for pain management, you can begin the conversation with others as to how to improve the situation in small but meaningful ways. Be intentional in your desire to improve the system. Just acknowledging the difficulties and expressing the desire to make improvements is often the first step. Seek out other individuals with interest in pain management. Or start the conversation yourself. Social media can be a great resource to seek out like-minded healthcare professionals who want to improve the visibility of pain treatment. I've posted about this previously. Check out the post here --> Let'sTalkAboutPain
On lack of pain management training...
Inquire within your institution about the pain management educational resources available to you. Seek out opportunities to learn more about how YOU can be intentional about pain management. This does not need to be time-consuming. The Press Ganey Associates is a company known for developing and distributing patient satisfaction surveys. As such, they are committed to assisting institutions in finding actionable activities to improve the delivery of pain care. You may have access to the Improvement Portal or inquire with your institution's Quality Improvement committee. In the post linked above, I also provide some resources as to the various pain societies that offer free resources for improving pain management.
On pain as the silent, invisible epidemic...
Let's bring the pain experience into the light. The pain experience can be a lonely one. While it would seem that the world rallies around the individuals with an obvious condition, pain on the other hand is largely an invisible condition. Patients often feel overwhelmed when told 'you are too difficult for me' or 'I have nothing else to offer you'. While we may have exhausted offerings from our armentarium as to medical treatments that are beneficial, we must provide the emotional and compassionate support our patients so desperately need. This support may be actively assisting the patient to find the appropriate provider for them and walking with them through the journey. This is the essence of primary care. Check out the link below for an exhaustive list of resources for chronic pain programs and providers. Reach out to others for assistance.
And finally, to all who say 'I don't do pain management'...
We are ALL pain management providers. I feel the deficit in our healthcare system currently is the lack of application of the biopsychosocial approach to pain management for every type of pain, acute or chronic, minor or major, on a daily basis. It is this misconception, that only pain fellowship-trained providers 'do' pain management which contributes to the difficulties our patients are facing today.
The biopsychosocial approach to pain emphasizes that pain is an emotional experience and not simply the result of activation of nociceptors in isolation. The Gate Control Theory of Pain demonstrated that there is an inseparable interaction between psychosocial and physiological processes and this results in a complex interplay with differing results dependent upon the individual. Take a look at this article for great information.
In order to honor this reality we must treat ALL pain with this biopsychosocial approach, from the acute pain experienced after a surgical procedure, physical trauma, a medical condition and into the chronic pain condition. When we fail to do so in the acute setting, this makes individuals with developing chronic pain suspicious of our intentions when recommended to seek counseling through psychological services to address coping strategies and explore emotions.
In the optimal acute pain management plan, pain is approached in a biopsychosocial manner. Rather than only offering pain medication and treatments after a surgical procedure, we must concurrently address the various emotions that can arise.
Fear, anxiety, isolation, helplessness, grief, to name a few.
Fear of more pain with movement or activity; fear of what the pain might mean
Anxiety of pain, missing out on social activities, being able to cope
Isolation from friends, typical activities, not being believed
Helplessness of not having control of pain