Chapter 27
Conclusions
the future
In the 12 years since Pain: A Textbook for Therapists was published, much new knowledge has been gained about pain. Gatchel et al (2007) have described an ‘explosion’ of research into chronic pain, in particular, with a resultant increase in knowledge about its cause, assessment and management.
Much more is understood about the complex physiological mechanisms which happen at the periphery when we are injured, and what is happening in the central nervous system of the individual in pain. The poor correspondence between disease and resulting symptoms has led to a call for treatment, based on the underlying pathophysiological mechanisms (Woolf & Max 2001). This has led to revolutionary changes in the investigation of neuropathic pain and complex regional pain syndrome (CRPS) (Maier et al 2010). Meanwhile, advances in real-time brain imaging have enabled us to link subjective pain experiences with physiological changes (Bushnell et al 2004). These and other developments are giving us a better array of pharmacological agents than ever before. Our understandings about how to minimize or prevent acute pain from transitioning into persistent pain have grown. As identified in Chapter 9, our understandings of the psychology of pain has expanded greatly, as has the psychological armamentarium now at our fingertips. We are better at educating our clients and patients about their pain and now, we value the people who suffer pain more, and even at times, work in partnership with them, rather than doing to them. This is clearly amplified in Mandy Nielsen’s chapter (Chapter 2).
We have a plethora of Clinical Guidelines to assist us in our work. There are numerous Clinical Guidelines and Consensus Statements, of which clinicians worldwide can avail themselves. For example, the American Pain Society published its Guideline for Management of Cancer Pain in Adults and Children in 2005 and the Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain in 2009 (Chou 2009). In Australia, the National Health & Medical Research Council published the 3rd edition of its Acute Pain Management: Scientific Evidence guidelines in 2010 (Macintyre et al 2010) and the Australian Pain Society published its Evidence-based Recommendations for the Pharmacological Management of Neuropathic Pain in 2008. Similarly, the British Pain Society has published a range of guidelines covering spinal cord stimulation, cancer pain management, acute pain in children and paediatric anaesthetics. The UK’s National Institute for Health and Clinical Excellence (NICE) continues to produce guidance for treatment based on current evidence. Consensus statements abound, for example, An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons (Hadjistavropoulos et al 2007). There is indeed a wealth of knowledge out there.
Yet, as has been frequently mentioned in previous chapters of this new book, and in other literature such as Cousins (2007), our pain management practices remain patently inadequate in many quarters. As Brennan and Cousins stated in 2004, ‘The gap between an increasingly sophisticated knowledge of pain and its treatment and the effective application of that knowledge is large and widening’. Such gaps exist across the spectrum of acute and chronic pain; across pain in the elderly and pain in the young; pain in developed countries and pain in developing countries. Wittink and colleagues opined, in 2008, that the best treatments for people with chronic pain remain ‘elusive’. There is also inadequate acute pain management. Surveys of patients who undergo surgery repeatedly reveal unrelieved post-operative pain (see, e.g. Apfelbaum et al 2003). Apfelbaum and his colleagues (2003), in a national telephone survey in the USA, of a random sample of 250 adults who had undergone surgery, found that almost 80% had pain after their surgery, with 39% of these people experiencing severe to extreme pain. Some 88% of patients who had received pain medication were satisfied with the medication. Three-quarters of this sample believed that pain after surgery was a necessary evil, with 72% saying they would prefer a non-narcotic drug due to fears of addiction or bad side-effects of narcotics.
Pain management for children, including those children who are dying from cancer, is insufficient. For example, in an interview study of parents of children who had died from cancer over a 9-year period and who had attended one of the biggest children’s hospitals in Australia, 37 families (46% of respondents) reported that their child had suffered a lot or a great deal from pain in the last month of their life (Heath et al 2010). The comprehensive Access Economics report The High Price of Pain (2007) identified a lack of data on the prevalence of chronic pain among children in Australia.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
