Chronic pain: how to live with it and man­age it

Nurse-led pain man­age­ment pro­grammes aim to im­prove the qual­ity of life for peo­ple with per­sis­tent pain

The Irish Times - Tuesday - Health - - Health Pain Management - Co­lette Sheri­dan

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.

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.”


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.”


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 my­painfeel­s­

It’s about liv­ing with it in a pos­i­tive way and putting lim­its on it so that the pain doesn’t con­trol you


The results of a re­cent au­dit (left) con­ducted by Grunen­thal Pharma Ltd and Chronic Pain Ire­land show that back and joint pain are the most com­mon types of pain.

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