The Denial of Chronic Pain

[Guest guest]

This was sent to my CFS/FM mailing list.

It's quite long, but it's certainly well worth reading if you can manage

it.

Thankyou, Ken for your note about opiate-phobic doctors ... I'm sorry that

you're in the same boat as me ... but then again, there's a certain relief

in not feeling quite so alone in this " abandonment to pain " treatment.

Kit.

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From: Ted Shaw[sMTP:tedshaw@...]

Sent: Saturday, 11 April 1998 13:34

To: ozme@...

Subject: The Denial of Chronic Pain

" The Denial of Chronic Pain " by W Teasell

http://www.pulsus.com/pain/02_02/teas_ed.htm

W Teasell MD FRCPC

There is a current disconcerting trend towards dealing with chronic pain

and its subsequent disability by denying its reality. The reason for this

has primarily been cost containment and cost reduction. The monograph on

Back Pain in the Workplace probably best reflected this philosophy wherein

pain was defined as activity intolerance and disability as unemployment

(1).

Recently Bill 99 in the Ontario legislature has put forward changes in the

Workers' Compensation Board's provision that, in essence, limit patients'

medical and compensation entitlements to anywhere from six to 13 weeks

depending on the nature of their job. Responsibility for rehabilitation and

getting the employee back to work would be transferred to the employer.

Undoubtedly, accommodations by employers are essential in enabling injured

workers to return successfully to some form of employment. However, under

the new proposal, the employer is only responsible for trying to provide

suitable or comparable work, and the temptation to deny workers' injuries,

particularly in nonunion environments, will no doubt be high.

This approach is a radical departure from previous policies. Models of

chronic pain management through denial are based on the proposition that

chronic pain occurs as a consequence of compensation and inappropriate

treatment. Moreover, they emphasize the outmoded concept that soft tissue

injuries heal after six weeks, and they cling to increasingly irrelevant

behavioural models of chronic pain.

The irony of these developments is that they come at a time when we

understand the physiological basis of chronic pain better than ever before.

As well, the concept that chronic pain is largely secondary to compensation

or psychological factors has been largely refuted. Scientific evidence of a

physiological causation for ongoing chronic pain is well recognized (2-4),

and even the biopsychosocial model recognizes the importance of organic

factors in chronic pain.

Chronic pain disorders generally develop after a repetitive low impact type

of trauma or a single high impact trauma. Much of the debate regarding

persistent pain revolves around the normal anticipated time for

musculoligamentous healing to occur. There has long been a misconception

that all injuries should heal after six weeks. This rationale is based on a

few animal studies and the clinical experience that the majority of

injuries

do improve within six weeks (5). However, clinical experience and follow-up

studies (6,7) clearly demonstrate that not all patients necessarily get

better and that there is a significant subset who continue to suffer from

chronic symptoms. Some become disabled, depending on both pain intensity

and

psychosocial factors, such as the type of employment in which they are

involved.

Ironically, in sports medicine it is well recognized that many professional

and nonprofessional athletes have longstanding injuries that are soft

tissue

in nature, which do not get better with time or which require many months

of

therapy and abstention from sports. Such injuries have terminated many

promising careers. The legislation in Bill 99 for the Workers' Compensation

Board of Ontario proposes standards for injured workers that could not be

met by many professional athletes, despite that they are highly motivated

and in top physical shape, have the best medical care and trainers and

receive full compensation even when injured. Fortunately, such individuals

are not included in this proposed legislation, which, if extended to

prominent athletes, would result in a public outcry.

The evidence that chronic pain has an organic etiology is growing and has

become increasingly compelling. In the area of whiplash injuries, the work

of Barnsley and associates (4) in Australia has been particularly

interesting in that they were able to demonstrate that when local

anesthetics are used to block cervical facets joints, a majority of

appropriate patients experience reduction in their pain far in excess of

that from placebo injections. In addition, Lord et al (8) have shown in a

controlled trial that percutaneous neurotomies denervating these same facet

joints will significantly reduce or eliminate the pain of these individuals

for longer than six months. It is interesting that this highly impressive

research is largely ignored outside of, and to some extent within, the

academic community (5,9).

There is also impressive evidence of significant biochemical abnormalities

in disorders such as fibromyalgia; three independent studies demonstrated

levels of substance P in the cerebral spinal fluid that were two to three

times those in controls (10-12). As well, we know that, based on animal

data, there is significant evidence of neuroplasticity in the spinal cord

in

response to pain stimuli, which could account for the clinical picture of

regional pain syndromes (3,13). In these conditions, neurotransmitters such

as substance P have also been implicated. More recently, altered regional

cerebral bloodflow has offered opportunities to document a physiological

concomitant of the patient's pain experience (14). Despite this impressive

collection of physiological evidence about pain, the scientific evidence

does not appear to be reaching legislators or clinicians who seem

determined, based on ideology, to impose draconian alternative paradigms to

deal with chronic pain and, in particular, its associated disability.

To justify such an approach, psychosocial factors are often implicated as

causative. However, a wave of recent research has demonstrated that

psychological factors are more secondary to pain than causative (7,15-17).

The high incidence of psychological problems seen in tertiary care clinics

reflects tertiary care selection biases, and the literature, which largely

arises from such clinics, clearly also displays this bias (18). In fact,

the

problem may be more related to the chronic pain patient's unwillingness to

accept (and subsequently adapt to) their pain and its limitations (19).

Psychological difficulties occurring as a consequence of the pain and

subsequent disability are often misinterpreted as causative.

Individual coping mechanisms vary but this is true in any medical disorder.

Patients with rheumatoid arthritis can have significant psychological

difficulties, and it has been suggested that psychological factors

contribute to rheumatoid arthritis pain and functional disability,

independent of disease activity (20,21). Among spinal cord injured patients

with pain, over one-third of those who stopped working after the spinal

cord

injury said it was because of their pain and not their paralysis (22).

Interestingly, pain was regarded by these patients as a significant cause

of

work disability, even when the individual had a more 'acceptable'

alternative explanation (ie, paralysis) for work disability. It also

suggests that in some patients, pain is regarded as more disabling than

paralysis/paresis.

The controversy about chronic pain and disability is inevitably tied to

perceived secondary gain and the availability of compensation. Recent data

suggest that compensation is important, particularly in terms of the number

of claims, but that its importance has been overrated in terms of pain

because it accounts for only a small degree of the variance seen (6% in one

meta-analysis [23]). Its effect on claims is gradational, an expected

relationship. On the other hand, 'secondary gain' is a vague term that has

never been well explained (24). Anybody who treats these patients regularly

realizes that the concept of secondary gain also has to be coupled with

secondary losses, and most of these patients continue to have pain despite

that secondary losses clearly exceed secondary gains (24,25).

It is most disconcerting that the patients who will be affected by changes

in legislation are those shown to be at highest risk of disability - namely

those in lower socioeconomic groups, in particular those who are poorly

educated, who lack transferrable skills, are older and who are more likely

to perform heavy or repetitive physical labour (26,27) - most of whom would

be classified as 'blue collar' workers or the 'working poor'. Many are

immigrants with limited communication skills and/or working women who

appear

to be more susceptible to developing conditions such as repetitive strain

injury, fibromyalgia and myofascial type pain. Attempts to deal with

chronic

pain disability as a social problem will serve only to target individuals

who are especially vulnerable to withdrawal of support. This vulnerability

is further enhanced by significant changes in the availability of work for

individuals without specific technical skills and a decreased willingness

on

the part of employers to accommodate or compromise the workplace for

injured

workers. This is not only true for chronic soft tissue type pain but also

is

reported in conditions such as rheumatoid arthritis (20).

Canada is becoming increasingly less sympathetic towards the weak, the

poor,

the injured and the disadvantaged. This Darwinian mindset sees such

individuals as a drain on society and, in particular, contrary to the

economics of profitable business. Certainly the cost of disability is an

important factor that must be considered. However, we seem to have crossed

a

threshold where it is increasingly acceptable to demonstrate a lack of

empathy or compassion for anybody who is injured and, in particular, those

who have chronic pain. Governments not only fail to display compassion for

injured workers, but displaying such compassion is seen as weakness for not

staying the course of significantly reducing direct costs. As health care

professionals and researchers we have an obligation to point out to our

politicians and society in general that there is a significant human cost

to

proposed policy changes. Short-changing people when they are most

vulnerable

is going to increase suffering markedly while simultaneously swelling the

welfare roles and transferring the problem to other jurisdictions. Although

such measures may well force some individuals to return to work who might

not have otherwise done so, the fact is that the vast majority of

individuals are likely going to end up without resources at a time when

they

need them the most. Knowing what we now know about chronic pain, such an

approach clearly strains the ethical responsibilities we have for

individuals in our society who are limited by chronic pain.

--------------------------------

REFERENCES

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2. Merskey H. Regional pain is rarely hysterical. Arch Neurol

1988;45:915-8.

3. Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central

neuroplasticity to pathological pain: review of clinical and experimental

evidence. Pain 1993;52:259-85.

4. Barnsley L, Lord S, Bogduk N. Comparative local anaesthetic blocks in

the

diagnosis of cervical zygapophysial joint pain. Pain 1993;55:99-106.

5. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the

Quebec Task Force on Whiplash-Associated Disorders: redefining " whiplash "

and its management. Spine 1995;20(Suppl):1S-73S.

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and

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25. Freeman DW. Sick rule dynamics and chronic back pain in the injured

worker. Seventh World Congress on Pain, Paris, France. 1993;315:108. (Abst)

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--------------------------------

Department of Physical Medicine and Rehabilitation, University of Western

Ontario and London Health Sciences Centre, London, Ontario

Correspondence: Dr W Teasell, London Health Sciences Centre, 339

Windermere Road, London, Ontario N6A 5A5. Telephone , fax

, e-mail robert.teasell@...

Received for publication June 27, 1997. Accepted July 4, 1997

--------------------------------

---------------------------------------------------------------

Ted Shaw - tedshaw@... Phone/Fax (079) 381 277

28 Street Mt. , Queensland Australia 4714

Home Page: http://www.networx.com.au/mall/cfs

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