Prescribing wellness: a better way to manage chronic pain

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Welcome to the Australian Prescriber podcast. I'm Dr Ashlea, Broomfield your host for this episode and it's a pleasure to be speaking to Dr Newman Harris, pain medicine physician, about prescribing wellness in chronic pain. So, Newman, chronic pain is an extremely common problem and I certainly see this in my practice. I noticed an interesting fact from your article in Australian Prescriber is that scoring pain out of ten tends to elicit default opioid prescriptions and that was quite surprising to me. Can you outline some simple validated measures that GPs can utilise to better assess chronic pain and function?

There's quite a number of useful measures that we use and it's more surrounding not so much the intensity or severity of the pain experience, it's more about the level of intrusion that pain has to a person's daily life and the amount of impairment that that brings with it. So, one might look at something like the Örebro questionnaire or the catastrophisation questionnaire. Michael Nicholas's pain self-efficacy questionnaire is a very useful one. It's ten questions, each focusing on certain behaviours and certain attitudes towards pain such as does the person believe that pain means they should stop what they're doing? Do they think they need more medications? It gives a total score out of 60 and gives an indication of how well a person is coping. But within the questions themselves there are really important reflections of the individual’s attitude and beliefs that may be in need of addressing in reducing the fear that the patient has of getting things done and being more functional in life.

I've certainly seen that Örebro musculoskeletal questionnaire come across my desk or my desktop in different phases and it's interesting to me that it was initially validated to assess those patients on work cover cases that were likely to then go on to have chronic pain, but like you say, it's quite an interesting resource to elucidate perceptions that people have about their pain and what that means to them, and which you could then work psychologically with them about addressing those particular fears.

The Centre at which I work we use quite a few questionnaires and, whilst they're all very interesting in terms of what people's score is and they do give us certain indications of prognosis etc., I find them very useful clinically because if a person scores highly in some question reflective of aberrant pain behaviour or unhelpful pain beliefs, it gives us things upon which to focus while we're having a therapeutic interview.

And you've outlined some of these or your team has outlined some of these resources in the article. Are these things that could be incorporated into software and populated per se?

Well they certainly could be, and I think in some instances they have been. I really would stress that the score is of some benefit. Certainly, if you have a person who scores poorly initially and, after three months of suitable counselling and rehabilitation in relation to their chronic pain state, they score better, you've got an objective, a reflection of them doing well. But I still prefer the reflection of people taking less medication, doing more and being happier, both in their life and in their family, as the true indications of therapeutic success.

Yeah, their subjective improvement, which is what our patients really care about. Speaking of medications, we know that there's clear evidence that opioids have been shown to have no benefit improving function, however patients are often adamant that opioids are the only thing that improves their pain. What are some strategies that GPs can utilise to address these beliefs held by patients?

The most important part of getting people off opiates is pointing out to them that these medications don't actually improve their function. Then true gains are made by gradually and sensitively increasing their activity levels despite their pain and rebuilding the body. The longer they have been inactive or relatively inactive, the more they have deteriorated physically, and that pain they are getting is partly because they've deteriorated physically not because of their primary pathology in the first place. And they have to fight that back as does anybody who doesn't do any sort of exercise for a very long time.

We know that patient education of the neuroscience of pain is shown to be effective in reducing pain. Your team has listed some resources in the article that can help GPs to explain this to patients and there's a few good links to some YouTube videos. Another approach your team spoke about is activity pacing and behavioural activation strategies, which ties in with what you were talking about, you know, working with function rather than pain. Can you explain what these mean in practical terms?

These are things that I've had tremendous success with in one-on-one situations in my consulting room. If I take one patient in mind this was a person who was doing no activity at all and hadn't for a very long time, and I set up a program where she was going to take a walk out of the front door of her house to the letterbox of the house two doors away twice a day. Now of course that was a very, very small amount of formal exercise but it set her on a formal exercise protocol with which she herself acknowledged she could do herself no harm. And by undercutting any fear associated with that exercise program, and by making it a program contingent on anything but her pain – in this context it was doing it for a certain distance, one might do something for a certain period of time – one makes these activities contingent on some objective parameter that is not the pain. So eventually at an agreed rate we built up that activity from two doors away to four doors away to the corner to around the block and ultimately, I got that woman to go back to work part-time. And it really was a matter of what level of activity can I ask you to do every single day, rain, hail, sleet or snow, that is so modest you cannot possibly do yourself any harm with it?

So, it's like graded exposure for pain?

Well it's interesting you use the word exposure as if it's an anxiety disorder, because what we're addressing here is the patient's fear of incurring more pain or of doing more damage to themselves. So, it is exactly that. By negotiating with the patient a level of task with which the patient is comfortable that he or she can do no harm or not get an unreasonable level of pain for that activity, we're undercutting that anxiety, we're giving the patient the control over the task themselves and, yes, they can then do that as contracted every single day, rain, hail, sleet or snow, and they get the runs on the board and they feel more confident with themselves. We haven't set a task which allows them to determine that they're going to stop it now because they've been overwhelmed by pain. The pain is no longer going to become the parameter by which they determine whether they continue or stop things.

What do you do with the really difficult patients when you're trying to negotiate with them about what can they do that doesn't give them pain and they keep saying nothing, everything gives me pain, there's nothing that I can do that doesn't get me pain? What kind of strategies can you utilise with the really difficult, stuck patients?

Some patients will be very difficult to shift, and it does take some time to encourage them to get moving. And we also have to discuss things with the support structure around them. And this is more significant with certain personality styles, certain cultural groups. There's a whole bunch of variables that will affect it. But ultimately a pain patient is being supported in their position by family members, other health practitioners and so forth, and unless we also affect shift in the attitudes of those support structures, we're not going to affect a useful change. Even if the patient is prepared to do the things which we advise and ask, their families can quickly push them back into their position of helplessness by insisting, oh no, no, don't you go and get that cup of tea, I'll do it because you might hurt yourself. Well, that's preposterous. And how many patients have I encouraged to get up and how many patients’ wives have I encouraged to say to them would you like a cup of tea dear? And when the patient says yes, she's to say good, then you can make one for me too.

So, are there any favourite language or phrases that you use to explain to patients about how to do this or reassure them about the process?

Most importantly one has to pitch one's language for the patient. The important things I impart is that I have seen people do very, very well by embracing this paradigm of getting their life back, and that's a term that I like to use. I like to say we're not here to fix your pain anymore. You've seen all the king's horses and all the king's men. Obviously, no one's going to fix your pain. But wouldn't you like to have your life more normal, more like it used to be despite the pain, if we can help you to achieve that? And most people will say yes, and then you say that there's been a great deal of success in helping people normalise their lives and be more effective members of their family for their spouses and for their children by following this paradigm, and being just a little bit brave, just a little bit brave, and taking on stuff that seems challenging and counterintuitive.

Hmmm. I like that. Can you outline the role of nutrition and social engagement in the management of chronic pain?

We've seen more recently research indicating that there are quite substantial inflammatory processes going on within the central nervous system, and these are contributing to the unfortunate feedback processes of persistent pain, particularly with neuropathic but in fact with all pain processes. And these are fuelled in part by adipose tissue in the body. So, people who are carrying a bit more fat are actually releasing inflammatory chemicals into their systems, which make this sort of problem worse. Those same chemicals have been implicated in mood disorder. Of course, mood anxiety disorders are intimately enmeshed with chronic pain syndromes. So, for those reasons it's very important that people eat a healthy diet and wherever possible build up towards a useful amount of aerobic activity. Social activity is part of living a more normal existence for oneself, for one's family, and it also allows one to de-emphasise pain as a central process in their life. I encourage patients to train the people around them to stop asking them about their pain. I believe that neuroplastic changes allow the continual discussion of pain and the continual consideration of pain to actually promote the pathway’s attentional on pain process, and that, by training the patient and the people around the patient to think about anything but pain, is actually therapeutic to the central nervous system processing of pain state.

So basically, wellness activity functions in a holistic way with our patients and not just looking at what it is that they're presenting with us and complaining about, but also looking at their entire existence and how we can improve their nutrition, engagement socially, physical exercise and activity and, of course, mental health wise and psychologically. So what are the most effective treatments or psychological treatments for chronic pain?

The most effective psychological inputs are things from the cognitive behavioural realm. It's an extrapolation of cognitive behavioural therapy as originally developed for mood disorder. And as we've already reflected here, it's some ways very much like treating any sort of phobic process because in many ways we're talking about a phobic process. The patients who do best with their pain, in terms of having less disruption to their life and less reliance on seeking obliteration of the pain, but people who have a life despite it, the people who have other things to do and who get those things done. And what we want to do is say do you want this pain to run your life, or do you want to run your life despite the pain?

We also can't forget to address the other aspects of their existence which may be contributing to their pain, such as substance abuse or poor sleep.

A team-based approach is of course very helpful and the most important part of espousing a team-based approach is for the practitioner to explain to the patient that together you are a therapeutic alliance.

So, it's about empowering our patients to enhance their lives that enhance their function.

And it's a wonderful thing to watch a patient pick up and run with this sort of thing after they've been so tortured for so long with such problems.

Thanks so much for joining us today Dr Harris

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The views of the hosts and guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Dr Ashlea Broomfield and thanks for joining us on the Australian Prescriber Podcast.