Reflection – “Pain, pain, go away, come again another day”
Pain often has a negative connotation attached to it. Pain is defined as a highly unpleasant physical sensation caused by illness or injury, or it can be associated with mental illness or distress. One person can consider a little discomfort as pain, but for another pain can be an agonising impairment to their quality of life. Pain is therefore a subjective perception.
A study published in the British Medical Journal (Fisher et al. 1995) described the case of a builder who jumped down onto a 7-inch nail, which pierced his boot at the toe level (image below). The man was in so much pain he was given intravenous painkillers in the emergency room. However, when the boot was cut away, it turned out that the nail completely missed any part of his foot and was actually lodged in between his toes. This case was not of a man drug seeking, but of a man who truly believed he was in pain after seeing his own injury.
Pain is also a protective mechanism, where our brain tells us that something is wrong and that we should stop and do something about it. For example, we feel pain when we are burnt or when we get injured. But like many good things, pain can also become harmful, and this is what happens with chronic pain. As people experience prolonged and regular pain, they become more sensitised and ‘hyperalgesic’; and neurological changes start occurring in the brain. Pain then becomes less of a protective mechanism but more of an issue in itself, as it is always there, always uncomfortable, and always unsettling.
Chronic pain is now a public health issue. It is one of the most common conditions encountered by healthcare professionals, particularly among older patients (Reid, et al. 2015). Globally, it is estimated that 1 in 10 adults develop chronic pain each year (Goldberg & McGee 2011). A review article by Von Korff (2011) quoted higher figures: “Almost 40 per cent of adults worldwide report common chronic pain conditions…25 per cent of all adults experience chronic pain that interferes substantially with life activities, and 10 per cent have a pronounced disability in their social life associated with chronic pain.”
Regardless of the numbers, it is obvious that chronic pain is a growing public health concern as the average age in the developed world increases. There is now a big push towards developing new treatment modalities for chronic pain sufferers. Currently, management of chronic pain includes pharmacological treatments, meditation exercises, psychological treatment and surgery.
While on my anaesthetic rotation, I was able to observe different types of operations performed on chronic pain sufferers. One operation was the installation of a spinal cord stimulator for a middle aged female, who developed chronic regional pain syndrome in her left leg and foot following a fracture in her left tibial bone last year. The treatment aimed at relieving her pain cost around $50, 000 an amount unattainable for most people. The patient was awake for the procedure, and the expensive device, said to last at least 20 years, was installed in her epidural space. The intense operation lasted more than two hours.
Operations to help relieve (not cure) pain is risky, because the success rates vary; and in a worst case scenario an operation can make the patient worse by either exasperating the existing pain or creating new pain.
I feel that most people with chronic pain would do anything if given the chance to relieve their pain – even if it is risky and expensive. So, given a choice most people would proceed with surgery despite the cost on the public health system.
Chronic pain is an increasingly prevalent condition that negatively impacts patients quality of life. Currently, the treatment options are limited, costly and even risky. It is an important public health issue that needs addressing. An important step is to educate health professional the importance of understanding pain and how talk to patients about pain and its management. I feel a consultation or discussion about pain is not a light one and needs time, sympathy and support.
Fisher JP, Hassan DT, O’Connor N. Minerva. BMJ. 1995; 310:70.
Goldberg., DS, & McGee, SJ. (2011). Pain as a global public health priority. BMC Public Health. 11:770.
Reid., MC, Pullemer., K & Eccleston., C (2015). Management of chronic pain in older adults. BMJ. 350
Von Korff., M (2011). Public health approaches to chronic pain: the role of epidemiology. The Lancet, 10 (3) 210-211.
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