Chronic pain: how to live with it and manage it

Irish people have a frustrating time trying to describe the pain they suffer from. Chronic pain (which lasts for more than three months) affects 1.65 million people in Ireland, with back pain being the most frequently reported site of pain. Many of the afflicted have a difficult time trying to describe their pain in a way that allows doctors to really understand the potential cause and the impact on their lives.

Chronic pain is most likely to have a negative impact on a person’s ability to exercise, suffered by 73 per cent of people with pain. It affects 53 per cent of sufferers’ ability to work, and to socialise (45 per cent).

The “My Pain Feels Like...” campaign aims to help people explain their pain and receive an accurate diagnosis and treatment. A nurse-led pain management programme was rolled out across Leinster in 2017, aiming to improve the quality of life for people with persistent pain.

The results showed a 21 per cent reduction in the proportion of patients experiencing moderate to severe pain, a 6 per cent drop in the proportion of patients who missed work days in the last week due to pain, and a 60 per cent decrease in the proportion of patients waking three to four times a night as a result of pain.

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The campaign is a collaboration between Grunenthal Pharma Ltd and Chronic Pain Ireland. It is supported by Multiple Sclerosis Ireland and the Parkinson’s Association of Ireland.

Dr Rukshan Goonewardena, GP principal at Ballyjamesduff Family Practice in Cavan, ran the pain management programme in his own practice.

Chronic pain

"While the programme was funded by a drugs company, it's not really about the drugs," says Dr Goonewardena. "It was more about patient health management and what can be done on the patient's side to manage the pain better. Multiple GPs were involved."

Acute pain differs from chronic pain in that “when you have an injury, ‘useful’ pain results. This means the body is telling you something is not right. But chronic pain is not ‘useful.’ It lingers on and there can be no clear cause of it. Fibromyalgia and back pain are chronic.”

When a patient sees their doctor for chronic pain, the first thing the doctor does is establish that “it’s not sinister. Once any serious pathology has been ruled out, that’s when you get a diagnosis of chronic pain”.

The programme, rather than just looking at medication for chronic pain, is about using other techniques such as mindfulness, pacing and stretching exercises.

“The idea is that the patient comes to see the nurse [in a GP’s practice] who goes through the patient’s daily activities and finds out how their pain is affecting them. The nurse will then introduce mindfulness and pacing techniques. For example, instead of gardening and straining yourself for half the day, you work for 15 to 20 minutes and then take a break to prevent exacerbation of pain.”

The idea behind the programme is knowing your limits and pacing yourself so that you don’t overdo an activity and then pay the price for a few weeks.

“The main thing I see [arising out of chronic pain] is tiredness, low mood and broken sleep. They can’t get their day-to-day work done and then they can’t come to work so it becomes a vicious cycle.”

Mindfulness

Asked if chronic pain can be got rid of, Dr Goonewardena says: “It’s about managing it. There are various treatment options but that would be up to a pain specialist. In a general practice, there is treatment available medication-wise but I prefer to say there is not a pill for every ill. Managing pain may not make it go away 100 per cent every day. It’s about living with it in a positive way and putting limits on it so that the pain doesn’t control you. You can learn to control the pain.”

How can mindfulness work? “A lot of patients with chronic pain end up having mood difficulties as well. If you’re more aware of your mind and how you perceive the pain, that might help you to compartmentalise the pain and stop it from affecting the rest of your day. If a person is in chronic pain and it’s affecting their relationship, that person, through awareness, can say ‘it’s my pain that’s making me feel this way.’ They can then try and have a more positive outlook on the rest of their life.”

Dr Goonewardena admits that this is “easier said than done. But with practice, they can put the pain in its own place using mindfulness techniques. It’s about having a bit of ownership of the illness. The patient has something to do instead of putting the whole responsibility on the GP. That’s positive. The patient feels more in control of their pain.”

Implications

What are the implications of the results of the programme for GP practices around the country? “It’s a mixed message. It goes to show that with patient education, you can have positive outcomes. The problem for GPs is that when we’re stretched, we don’t have an appointment slot available and we don’t have a nurse available. GPs will say, ‘this is all well and good but where is the time to do it?’ Blocking off two appointment slots for patient education isn’t really a luxury we have. If GPs are enabled and resourced to do it, the programme will be taken up more. It’s important to make patients aware of the campaign.”

Dr Goonewardena says some patients think that “getting a scan is the be all and end all. But in most cases, X-rays and MRIs don’t fix the pain. Sometimes, unnecessary investigation can be misleading so it’s always best to be guided by the doctor who’ll see if you need a scan or not.”

Most patients would already be on medication for their pain. “Once the medication is optimised, there are other measures the patient can use.”

As for medicinal cannabis, Dr Goonewardena says “there is not enough evidence to say it’s of use. We can’t rely on anecdotal cases. At the moment, there are no guidelines to say it can be effective.”

For more information on the pain management programme, see www.mypainfeelslike.ie.