Issues Magazine

Editorial

By By Sally Woollett

Editor, Issues

An overview of what's in this edition of Issues.

Pain has been part of the human experience for as long as we’ve been around. It’s surprising, then, that widely agreed definitions of pain and associations devoted to its study didn’t really emerge in number until just under 40 years ago.

John Bonica, Chief of Anesthesiology at Madigan Army Hospital during World War II, had ample evidence of the need to treat pain, both acute (short-term) and chronic (longer-term). By the late 1940s he had established the first multidisciplinary group to approach pain management, and in 1974 he founded the International Association for the Study of Pain (IASP).

In 1979, and after four years of thought, the IASP defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. This definition has recently been revisited and remains unchanged, says nurse practitioner Sue King (p.4).

Of course, descriptions of pain pre-date definitions considerably – the description of pain can be highly individual. King describes Descartes’ 17th-century Cartesian model of pain: “a sensation generated by tissue injury and conveyed by specific nerves to the brain”. We now know that this model misrepresents pain’s role in the brain: “More than an alarm bell, the brain is a complex filter and is key to pain as a sensory and emotional experience,” says King.

Steve Semiatin (p.7) walks us through a history of pain relief, from Chinese acupuncture to alcohol and plant-based mind-altering substances. Surgical anaesthesia, a major breakthrough in acute pain relief, was the outcome of “vapour parties” using diethyl ether and nitrous oxide. “The most often used gases are isoflurane or desflurane. Occasionally muscle relaxants are added to the mix to make sure the body remains motionless during the operation,” says Semiatin of modern general anaesthesia.

Recent research is offering hope to those with chronic pain. Since the founding of the IASP, knowledge of pain has widened enormously, forming a new medical specialty, says pain specialist Michael Vagg (p.12): “Australia’s Faculty of Pain Medicine … was the first professional body in the world to achieve specialty recognition by the Australian Medical Council in 2005”.

To understand how a brain with chronic pain is working, neuroscientists at the University of Oxford in the UK are using functional magnetic resonance imaging. According to Vagg, the results suggest that “long-term pain is far more of a degenerative brain disease than anything going on with the body part where the pain is felt.” Other studies suggest that, due to changes in the brain, people with chronic pain experience the world differently.

Bonica’s recognition of the importance of a multidisciplinary approach to pain is still upheld today. “Historically, pain reduction was considered paramount,” says Elizabeth Carrigan (p.15). “Now, however, there is increasing focus on improving activity levels, reducing psychological distress and raising functional capacity.”

The Pain Link helpline at the Australian Pain Management Association, of which Carrigan is CEO, is receiving more calls from people experiencing problems with opioids, such as tolerance difficulties and dependence. Thus the multidisciplinary approach needs to extend to coordinated care – involving GPs, pharmacists, hospitals and nurse practitioners – for patients in terms of medication delivery.

Emeritus Professor of Neuropsychology at Monash University, John Bradshaw, says he began his research into pain empathy after being approached by the widow of a man who during his life would experience severe pain when he witnessed it in others (p.20). This has spawned work in several areas, including exploring how mirror neuron systems (which match externally observed events to internally generated actions) are involved in understanding another’s experience of pain – a form of synaesthesia.

Women report pain of more intensity than that of men, according to a Stanford University School of Medicine study that used data from a large electronic database of medical records (p.24). Interestingly, “the search also unearthed previously unreported gender differences in pain intensity for particular diseases”. Further research is needed to determine whether reported pain is actually more intense or just reported as such.

We can do better when it comes to managing pain, says Natalia Valentino at Arthritis New Zealand (p.27): “An Australian survey in 2012 showed 80% of people with chronic pain are missing out on treatment that can improve their health and quality of life”. Regular exercise, medication, relaxation and access to a team of health professionals are all important in the management of chronic pain.

Social support is particularly critical in the management of paediatric pain. “If left untreated, chronic pain not only places a physical, emotional and financial strain on the affected children and their families, but also on their support network – their friends and their school,” says anaesthetist and pain medicine specialist Kathleen Cooke (p.30). The relative invisibility of chronic pain, coupled sometimes with the outmoded belief that children don’t suffer from it, are barriers to treatment.

The costs of pain to society are varied and high. In Australia, economic costs alone have been estimated at $34 billion annually. “There are potentially vast gains to be made through prevention, community awareness, early intervention, and better access to pain management services. An important facilitator of this is the fact that chronic pain is increasingly recognised as a disease entity by the relevant international bodies,” according to the National Pain Summit Initiative, which published its National Pain Strategy in 2010 (p.34). The recommendations of the strategy are now becoming recognised.

When Coralie Wales (p.38) visited her local federal member to discuss chronic pain, the response she received made her realise the extent of “misunderstanding and disbelief” about the issue. The founder of Chronic Pain Australia decided to devote her efforts leading up to National Pain Week 2012 to a campaign aimed at starting a debate about how education might close the knowledge gap. The team at Chronic Pain Australia was unsure about the chance of success of a campaign that asked people for paper petitions as well as online interaction: “We were wrong. Over the months before National Pain Week, the envelopes arrived. People had gone on their own campaigns.”

“Palliative care will affect all of us at some point in our lives,” says Jennifer Tieman at the palliative care knowledge network CareSearch (p.42). Pain is often a problem in illnesses from which there will be no recovery. As the end of a person’s life approaches, an understanding of all aspects of their pain – physical, emotional and/or spiritual – is needed for proper pain management, Tieman says.

Where recovery of health is possible, rehabilitation is sometimes helpful. Describing pain can be difficult. Thus, “as the complexity of someone’s pain unfolds, so may the rehabilitation strategies alter over time,” says rehabilitation specialist Geoffrey Speldewinde (p.45). He concurs that the multidisciplinary approach in a rehabilitation setting is appropriate because pain in itself is a multifaceted experience.