Setting the Meeting Tone: Defining Chronic Pain

Summary of SIP Symposium 18th November, 2014, Brussels, hosted by Marian Harkin, MEP, European Parliament.

Introduction:

The 5th Societal Impact of Pain Symposium, attended by policy makers, MEPs, politicians, government officials, representatives of patients’ groups and health care professionals from across Europe was opened by Dr Chris Wells

http://www.efic.org/img/lists/144/cv/chris_wells_cv.pdf

President of EFIC, the European Pain Federation of IASP Chapters, which represents 37 countries and 20,000 healthcare professionals throughout Europe. Dr Wells thanked Ms Marian Harkin, MEP, for hosting the meeting and the Italian Government particularly for putting pain and palliative care on the agenda during their presidency of Europe when they had called for prioritisation of pain therapy and palliative care. At meeting in Milan in September 2014 hosted by the Italian Minister of Health it was decided that all European Ministers of Health would prioritise healthcare professionals’ training and particularly look for effectiveness of pain therapy for the about 100 million people in Europe impacted by pain.

The SIP annual meeting aims to a make a major contribution to pain care in Europe. This year’s 5th SIP meeting, moderated by Nick Ross, renowned English radio and television presenter, was arranged as four interactive panel discussions over the course of the day.

Panel 1 discussed the reasons for and causes of continued inadequate pain treatment; Panel 2 looked at the different options in treatment and management of pain; Panel 3 looked at the Italian initiative and how this could be leveraged across Europe to make pain treatment more effective and Panel 4 discussed the milestones to determine managing and measuring progress and improving the situation.

Setting the meeting tone: defining chronic pain

Moderator Nick Ross introduced a videotalk by Dr Elliott Krane, Professor of Pediatrics and Anaesthesiology, Stanford University School of Medicine. Professor Krane discussed the onset of windup and mechanisms involved in the transformation of acute pain to chronic, outlining the phenomena of allodynia and hyperalgesia underpinned by the plasticity of the central nervous system. Dr Krane’s message was very optimistic in that he considers that drugs will be developed for the future targeted treatment of the disease of chronic pain rather than, as currently, chronic pain being treated by a symptom modifying perspective which requires a complex, often lengthy, multidisciplinary treatment approach.

Panel 1 discussion:

Professor Hans Kress, former President of EFIC, endorsed the description given by Prof Elliott Krane regarding the awful burning pain of hyperalgesia and the experience of the person experiencing chronic pain. Professor Hans Kress described how acute pain is a normal response to potential or actual tissue damage and is warning signal which, under normal circumstances disappears spontaneously when a wound is healed. In contrast, chronic pain is a constant, uninvited companion for the remainder of the sufferer’s life with many unpleasant psychosocial consequences such as anxiety, depression, social isolation and poor sleep, leading to reduced mobility and reduced activity with a consequent possible loss of working ability and capacity and ultimately disability. Chronic pain is a disease. Chronic pain differs from other types of disease in that there is usually or frequently no visible or obvious tissue damage because the neuroplastic changes which underpin the person’s chronic pain experience have taken place within the nervous system. Chronic pain is notoriously difficult to treat and currently, frequently no specific analgesic drugs alone can accurately treat chronic pain which requires a complex multidisciplinary approach.

Dr David Hughes, Professor of Health Economics, University of Chester, detailed the social consequences of chronic pain and the numbers involved. Approximately 100 million people in Europe suffer from chronic pain, 500 million sick days are caused by chronic pain, with a cost to Europe of about €34 billion per annum. Approximately one person in five with chronic pain loses their job, which affects the person and his or her family as well as the abilities of economies to function correctly. About 3-10% of GDP is lost because of chronic pain and across the board health resources are utilised more intensively for chronic pain more than for any other disease. Chronic pain has a major negative impact on the quality of life of the patient and his or her family. One person in six with chronic pain would prefer to die, with profound personal, familial and social consequences.

Dr Shelagh Wright, Psychologist, author, pain educator and retired nurse commented on the need to improve healthcare professionals’ knowledge and skills for understanding and treating the person with pain. Dr Wright commented that, ideally, legislation is required to ensure instigation of a mandatory undergraduate core curriculum which includes pain management for all healthcare professionals in the multidisciplinary team to improve standards of care for all patients with all types of pain. Inadequate knowledge and skills on the part of health care professionals leads to poor decision-making at all levels of the healthcare system which impacts on patient treatment and ultimately on patients’ safety. Dr Wright commented that in Ireland the implementation of the 2nd National Cancer Strategy made a massive improvement to quality multidisciplinary care for patients with cancer and that currently the focus was now on improving standards of care for patients with chronic pain of non-malignant origin.

Dr Maria Teresa Garcia Bacquero, Coordinator of the Regional Palliative Care Programme, Health Care System of Madrid commented that sometimes lack of understanding of the patient’s pain experience leads to problems from a teaching perspective One problem is caused by inadequate knowledge of correct pharmaceutical interventions in palliative care for example and so health care professionals require both optimal education themselves as well as the facility of rapid access to specialist knowledge for patients who require complex pain interventions. Harm is done when the wrong drug is given for the wrong treatment due to lack of knowledge and skills. From this perspective access to specialist knowledge is essential for patients who require complex treatments.

Moderator Nick Ross described how often there is no policy in place when a person needs treatment for either chronic pain or acute pain. Untrained and uneducated healthcare professionals can be completely ignorant of how to treat each type of pain and there is no standardisation of knowledge across the health care system. Prof Hans Kress commented one of the major problems is that chronic pain does not fit with a traditional disease concept, so someone who is in a lot of chronic pain usually does not have obvious tissue damage that can support their statement of their pain experience and distress. One of the major requirements for healthcare professional training is a change of mindset in understanding the pathophysiology of chronic pain. Another problem for both acute and chronic pain is that the patient’s pain is not objectively measurable, so what the patient says has to be believed.

Neal Betteridge, Vice Chair of the Chronic Pain Policy Coalition (CPPC) UK, commented that this is a problem that can be addressed by regarding the patient as part of the health care team, which happens in more enlightened locations. Patients need to be represented, their voice needs to be heard and they need to work with healthcare professionals in all aspects of patient care from policy design, education and clinical practice. Prof Hughes commented that problems of budgetary restraints could be overcome by seeing the benefit of utilising effective treatment for chronic pain to improve patients’ health related quality of life. A concerted approach to chronic pain treatment can maximize health benefits across populations.

Panel 1 members summarised the major obstacles and problems in terms of requiring quantification of the issues, prioritisation of treatment of populations with chronic pain, legislation to ensure mandatory teaching to enable optimal knowledge and skills at undergraduate level, promotion of consistencies for policies and standards for patient care, underpinned by the need for a cultural shift in attitudes.

Panel 2 Discussion: President of EFIC Chris Wells stated that, even though major obstacles of quantification and qualification existed, in his opinion the biggest problem is system failure. For example, in certain locations even though oncologists have the knowledge and skills to adequately treat patients with cancer pain they don't. Reasons for this are multiple and it seems that, in these instances where the knowledge is available and yet the system fails, cultural issues are at play.

Dr Meherzin Das, Consultant Clinical Psychologist and Clinical Lead, Dorset Community Pain Service commented how she has, for the last 10 years, been inspired by the stories of people who live with pain. Dr Das described how her experience in working with patients with pain made her realise that often patients present to the health care system far too late and don't seek treatment early because they don't think they're going to be believed by healthcare professionals. This realization prompted Dr Das to lobby for funds for early interventions for patients with chronic pain. One of the elements that she had to change was the slow referral patterns of GPs for psychological interventions for patients with chronic pain. Dr Das considers that use of the term ‘chronic’ may be part of the problem in that both patients and healthcare professionals subconsciously consider that chronic pain has to be there in the long term before it is actually addressed. Dr Das suggested that pain that is transitioning from acute to chronic should be treated at an early rather than later stage and early intervention should be encouraged. This involves health care professionals really understanding the neurophysiological substrate mechanisms involved in the etiology of chronic pain. Establishing an early patient referral and intervention pathway could contribute to solving the problem of chronic pain.

Audrey Craven, President of the European Alliance of Neurological Associations commented on the importance of education for patients as well as for healthcare professionals. Patient education is an extremely important aspect of self-management. Patients need skills to manage their pain and Audrey has taken the approach of asking policy makers the question ‘ if we can learn to self manage our pain disorders, what can you do to provide the services we need and how can the services be properly staffed with healthcare professionals who are fully trained and educated?’ Ms Craven described how the stigma of being considered as ‘malingering’ and ‘making things up’ is putting patients off admitting they have a problem. Patients may suffer in silence for a long time. Consequently, when they eventually seek help, their pain problem may be very serious.

Orsi Nagy, Policy Officer at the European Commission, outlined the importance of politicians

recognizing the financial benefits of addressing the population issues regarding chronic pain. Currently in the European Parliament the emphasis is on growth and jobs. The concern needs to be at the societal level in terms of the person affected by pain, how much a multidisciplinary intervention would cost a member state for that person and comparing that cost to the long term costs to the state both in terms of economic benefit in enabling the person to return to the workforce with not doing so. Associated costs related to disability, health and job loss to the state and massive reduction in quality of life to the person should be factored in to the equation. Early diagnosis and proper treatment on a population basis would be highly beneficial for society and for the economy. Health care education and training are political requirements. The aging population will double by 2050. Nearly half of all of health care professionals in Europe are currently aged over 45 years of age, so there is a strong argument for a societal perspective which focuses on early rehabilitation and the prevention of both chronic pain and disability for patients and optimal education and training for health care professionals. Quantification of the problem and evidence of intervention effectiveness would be hugely helpful.

Jamie O’Hara Director Healthcare Decisions and Senior Lecturer in Health Economics at Chester University stated that chronic pain is a problem that cannot be ignored and early diagnosis is key otherwise ‘the ship has sailed’. Currently across Europe 50% of patients are not diagnosed with chronic pain in the first year; 72% of those patients have their work life affected and 42% aren't able to return to work. A large study of 840,000 patients with chronic pain in Sweden looked at the patterns of work, cost and caregiver burden. In this Swedish study 10% of the entire yearly GDP was lost due to chronic pain. President of EFIC Chris Wells stated that at the European level chronic pain is recognised as disease but this legislation has to filter down to member states with the required implementation of service referral pathways, health care education and training.

Moderator Nick Ross encouraged audience participation in this second panel session. Dr Chris Baker, General Practitioner, said that clinicians need to be bothered about pain which is a cultural issue. Dr Barker described three components to the problem for General Practitioners: sufficient time to adequately assess the patient; optimal education to allow the General Practitioner have the ability to make the correct decision because frequently they do not have the education required to do that currently and thirdly appropriate patient referral pathways to appropriate services.