20min chapter

Feel Better, Live More with Dr Rangan Chatterjee cover image

How to Break Free from Chronic Pain and Reclaim Your Life with Professor Peter O'Sullivan #472

Feel Better, Live More with Dr Rangan Chatterjee

CHAPTER

Rethinking Chronic Pain Management

This chapter examines the challenges of treating chronic pain, highlighting the limitations and risks associated with conventional interventions like opioids, surgeries, and scans. It advocates for patient empowerment, effective communication, and a shift towards non-interventionist approaches to foster long-term well-being. The discussion also emphasizes the importance of emotional and lifestyle factors in pain management, promoting collaborative efforts between patients and healthcare professionals.

00:00
Speaker 1
So what's happened is, you know, what's really
Speaker 2
happened the last 20 years is this kind of escalation of what we would call low value care. Care that's expensive, it comes with risk and it doesn't do much good or it's got limited benefits. So if you think of the whole opioid story for chronic pain, we know it doesn't do a good, we know it's not effective. Opioids are not effective for chronic pain. They come with lots of risks, they have lots of downsides. So they just haven't been a helpful drug.
Speaker 1
I agree they've not been helpful. They've been downright harmful. Yeah. Right. It's not unhelpful. Yeah. He's a profession. Yeah. Yeah. Knowingly, stroke, unknowingly, have made so many people addicts. Yeah. Horrible. It is. I've seen it. It's horrible. I've seen it. It's not been neutral at all. And more importantly, you're saying that for chronic pain, it's not helpful. We know it's not helpful. There was a landmark study last year published in the Lancet that looked at
Speaker 2
opioids for acute back pain versus placebo showing that the placebo was more effective right out to 12 months. So, we just don't have good evidence for it, but the risks are significant. So, you know, but what I think what happens is in primary care, because we don't effectively manage back pain well, we start escalating, you know, and the scan is a driver of that. Because if you have someone who's, you know, you got the disc degeneration story and you've had, you know, various treatments not working and the patient's getting more distressed, the GP is going, well, we better send you to the surgeon. The surgeon goes, well, you've got a degenerate disc there. You know, you got this, you know, your surgeon gave you a wonderful advice, but that's not always the case. Then they're like, well, the patient's desperate. We confuse your disc. And we know the evidence for fusion and disc replacement shows that, you know, there are significant risks that come with that surgery. And the effect, the outcomes are no better than non-surgical treatment. So why are we doing it? And not only that, we know that the things that have been operated on and not predictors of that
Speaker 1
person's pain and visibility. So what are we doing? One of the most important questions I think any patient can ask their doctor is this, what happens if I do nothing? Right? And we need to normalize that more. Right? There's an idea that I've got a problem. I'm now going to the healthcare professional to get fixed. Okay? And the healthcare professionals with all their training are doing the best that they can in the system in which they're having to work. And often that means that there's a kind of unwritten idea out there that you have to do something to validate the fact that this was a consultation. Which is about us, right? As a healthcare practitioner. Yeah. And we... And I've been here before, so I totally get it. You feel like if you've given them a prescription, you've given them something, you've done something, right? So you feel satisfied, you've contributed here, and your hope is... And I think patients do feel... You know, some patients also will go in with the expectation that going to a doctor means I must come out with a prescription. We've created that. Yeah. So it's not just, this is not just healthcare pressures, it's also our public perception is that it's only worth it. I took half a day off work, I've waited two weeks for this appointment. If I don't come out with a prescription or a referral or a scan, it was a waste of time. And so the system also is playing into this.
Speaker 2
It is. Where people are wanting these quick fixes, but they're not neutral. We're not honest. Look, physios are caught in the same cycle. There's this perception is if I go and see a physio and I'm not put on the bed and given a rub down or mobilized or whatever, I haven't had treatment. Like good care is giving people a clear understanding of what's going on. Good care is about empowering them to make change in their life, to get back to the stuff they value. That's good care, but we don't value it. This is one of the reasons why I do this podcast,
Speaker 1
honestly, right? Because let's take it away from pain for a minute. Any GP or doctor knows this scenario, right? Someone's coming to see them with a cough, right? Yeah, it's affecting their life, it's bothering them, it's affecting their sleep, they can't work as well as they want to, etc, etc, right? So, they go in. The doctor examines them, looks for the red flags, looks for the signs and symptoms that might indicate a bacterial infection which may be down to violytics. More often than not, they're not there. There's no fever. There's nothing you can listen... When you're listening with a stethoscope, you can't find any sort of localized area of infection, right? And you just think, yeah, this is a viral infection. It's going to take anywhere from one week to four weeks or whatever to get better. So you try your best to reassure the patient, go, look, I get that you're worried. And of course, different doctors will do this with different approaches and some are better than others. But it's always my approach is always to try and explain and say, look, I get that you're worried, I get that you think this is serious, but honestly, I don't think it is. This will get better. It usually takes one to three weeks, but you know, sometimes it takes a bit longer, sometimes the cough can hang around. But here's what happens. And I do think society and our... You know, there's a lot of pressure on people at work. They don't want to take time off. Two parents are working, they're struggling. People have got difficult lives. So it's really easy. Two weeks later that patient's like, yeah, you know, I listen to the doc, but I just need some antibiotics now. I just need to all my life. Right? No one's at fault here. But the system, the medical system and the state of our culture now is such that people have no time and space to heal. So often that patient will end up back in front of the doctor and the doctor, even if they don't think it's appropriate, they will feel under pressure to give that prescription of the antibiotics. And then what happens is that a patient will often take it, and in that week they got better, but almost certainly it would have happened anyway. I'm not saying that antibiotics aren't sometimes indicated. What I'm trying to do is highlight that there is a systemic issue here for pain, but also for healthcare in general, that the system doesn't help, but also our understanding, our beliefs also
Speaker 2
don't help. 100%. Like, that's the story of back pain. If you look at most people who have an acute episode of back pain might go and see someone, but the evidence would say whether they do or not, the natural history, if they're gonna get better, they would have got better anyway. And if they weren't, the things we're doing probably won't prevent it. So, you know, that's again why we need to educate people about, hey, you know, for the majority, that's why those facts are so important. And know, there are some parts that NHS have put these into the system, which is super cool, because I think they're really helpful for people. Can I just ask, we turn up medical systems. And
Speaker 1
I guess how you hear this will depend on which country in which you live and what your experience of doctors has been. But one could argue that in private health care systems, people are incentivized to do scans.
Speaker 2
There's evidence for it. That are not needed. And to do procedures like injections. There is overwhelming evidence. Of what? Over treatment, over investigation and over treatment. Everywhere or in
Speaker 1
private healthcare systems? In private healthcare systems. Because people
Speaker 2
are making money. Yeah, massively. So, you know, if you look at America, I know, you know, the American system and Australia is not that different. We have a strong private healthcare system. If you look at the number of surgeries, spinal fusions in the public care system is pretty much flatlined and it's evidence informed. You know, like it might be, you know, an unstable fracture or something where a fusion is indicated. If you look at the work comp, so that's our work insurance system, which is a, it's a private system or our private health system. The number of those procedures exponentially increasing. The number of spinal injections is exponentially increasing. Hold on. So these things are increasing, but is pain going
Speaker 1
down? So that's the key, isn't it? Not at all. These things are increasing. If pain was also going down, you'd be like, okay, we're spending more money, but we're helping. That's why it's low value. That's why, yeah.
Speaker 2
I love these words, like low value or unhelpful. They're very kind words. If you think of high value care, it empowers people, it informs people, it gets them back to stuff that is important for them, but also cascades into other aspects of their life. That's the healthcare that we should be delivering people. But you know what? It takes more time, and that's the other tyranny of our health system, is that we have a health system that says, no, you cannot spend time with people. So if you can't spend time, you can't take history. You have no time to explore those different factors that are happening with that individual. You're forced to make quick decisions around treating symptoms, not dealing with underlying causes. So we have a massive issue in the way that we pay healthcare practitioners for time. In the REST or trial, they saw the practitioner seven times. That was it. And then- This is the trial you published in the Lancet. And so it was an hour for initial, subsequent, but we're between 30 and 45 minutes, seven sessions, right? With a follow-up at six months. These people have been through, God knows how much treatment before that. There was a cost saving, wasn't there? There was. And you know, the big cost saving is the people in the trial got back to work. Yeah. So not only was it $5,000
Speaker 1
per person per year for getting back to work. Some stats which I've learned through your work, which I think really speak to how badly wrong we've got it. In the US, $600 billion per year being spent on back At the same time, back pain is the largest cause for disability out
Speaker 2
of all health disorders. Those two starts, they don't marry up something. One is feeding the other. It's horrible. And you know, the saddest part is what we see is that people then had a fusion and they're not better. What next? What happens next? It's like, well, I've had... The gold standard treatment and I'm still... I've fixed my back and I'm not fixed. Yeah, because, right? If
Speaker 1
emotions were driving your back pain, if, and they're not in everyone, right? But if they were a significant part of your back pain, and you just deal with the biomechanics, but you don't address the emotions, of course,
Speaker 2
it's not going to go. But not only that, you know, once you've had a fusion, you get all these messages to be careful because you might do the next level. So not only that, we infuse people with morphia to overprotect the back. Do you think injections can work? Look, there's limited evidence, you know, for acute radiculopathy, there is some evidence for some short-term relief in terms of reducing radicular pain. For back pain, the evidence is really bad. Some patients will say, I think I've had an injection and it's not bad. But if you look at the evidence where you compare injection to placebo injection, they don't stack up well. But you know, we would say to people, look, it's around benefits and harm, right? So, it does come with some risks. Like I can't think of patients who have had a spinal leak, CSF after an epidural injection and ended up, affecting, hitting the jura, which is the coding around the spinal structures. And the spinal fluid leaking out. Okay. And I've been in hospital for 10 days. I've had others who've had spine infections. They've had a devastating consequence. Now, they are a low risk of getting that. But if you get it, it's a big
Speaker 1
deal. Yeah. And why I think understanding risk is so important. We've grown up in a culture where medicine is key. What the doctor says is king, right? Many of us have grown up in a culture where what the doctor says goes. And shouldn't be questioned. And shouldn't be questioned. And therefore, if the doctor is saying this procedure may help you, you take that on with extra weight. And I don't think we in health have enough of a conversation about risks versus benefits. Yes, there may be a risk of this operation, but there is also a finite risk of these problems. And then, like you say, if we compare it to placebo, is there really a benefit? Now, for some cases, of course there is, right? But again, if you don't have time in the system, no one's going to have these conversations. And to be fair,
Speaker 2
good
Speaker 1
surgeons are
Speaker 2
having these conversations. I mean, we have them, we have them too. Yeah.
Speaker 1
Yeah.
Speaker 2
And I'm sure everyone's trying to do their best. But, you know, we often see it as a failure in primary care that they end up being there in the first place, you know, like, you know, having to see a surgeon because primary care should manage the majority of people well. So they shouldn't have to go and see a surgeon if we're dealing with back pain, well, they'll get go. The other thing that I think you're tapping into here is that the problem with an injection is you're not empowered. You're having someone stick a needle in your back. It gives you short-term pain relief. There's no long-term benefit for it. So you just become part of another revolving door. So I wouldn't deprive anyone of pain relief. I never would. But this idea of, you know, we know it doesn't get them functioning again, it might reduce their pain, but it doesn't get them functioning. So if you have some pain relieving procedure, marry it with getting your life back. So at least use it as an opportunity to go through a
Speaker 1
process of getting your life back. Yeah, that's great advice. If that injection gives you relief for a couple of months, use those two months to put in place some great passes. And all
Speaker 2
the things we talked about then means you're likely to go back for another injection, significantly reduced. Okay, Pisa, you're doing incredible work in this field,
Speaker 1
honestly, and it's much, much needed. I really appreciate all the trials that you've published. We'll try and put links to them in the show notes. People want to check out your papers. Where are the websites that people should go and visit, both patients and healthcare professionals, if they want to learn more? Yeah. So just to highlight that I'm
Speaker 2
part of a big team of people, so it's not just my work. You know, there's a whole group of people behind that. So I would want to put that out. That's really important for me. I'm very privileged to work with some amazing researchers, clinicians. In terms of the opportunities for learning, the Evolve Pain Care Academy website, which is this social enterprise, will have a hub for patients, a hub for clinicians. All of that is free. So we want to create a way of empowering... Because we see it as this partnership. It's not enough to empower empower the clinician if the patient's uninformed, it's not enough to empower the patient if the clinicians are giving them completely contradictory advice. that's something, that's a place that we want to use to bring patients and clinicians together to work in partnership. So that's a great place. And on that also we have access to any open access material with summarize that there are patient stories, we've got patient advocates who are part of this process as well. So we're using their stories to kind of empower clinicians as well as people with pain. Love it. Okay, brilliant. The
Speaker 1
therapy you talk about, you've spoken about during this conversation, cognitive functional therapy, a lot of that will be on the website as well. Yes, exactly. And my interpretation of what I read was that there's kind of three components to it. There's one, making sense of the pain, two, exposure with control, and three lifestyle changes. Is that a reasonable summary? It is, yeah. Yeah, okay. I love it. It's so aligned with my belief around health and giving people agency and empowering them. To finish off this conversation, okay. There's so many people around the world who are suffering with pain and have done for many years. For someone right now who is in pain, who thinks there is no hope, what would you say to them? Well, I would say there is. There is overwhelming
Speaker 2
evidence that there is hope and that can seem glib or even insincere, but actually that's what our work has shown is that we're not promising a cure, but if pain is distressing and it's frightening and it's taking you away from things in your life that give you meaning, then there's hope for you. And part of that hope is to have a broader understanding of pain, to understand that our thoughts and our emotions and our behaviors and the way we use our body can drive pain in our body. And similarly, to turn that around is to shift the way we think, to acknowledge those emotions, to build confidence back in the body, to address other lifestyle factors around physical activity, sleep, relaxation practices. They're all part of the jigsaw puzzle. And for everyone, the pieces of the puzzle are a bit different. And so, you know, empowering people to kind of be self-reflective to go, hey, what are the key elements of my pain? What are they? And then, you know, we've had people contact me saying, I've been, I've looked at your website and I've looked at your videos and I want to thank you that for the first time in 20 years, I've relaxed my body and I'm starting to move again and I'm feeling hopeful again. For others, they go, I've seen it and it resonates with me. Where can I go to find help? And one of the things that we're doing is putting up clinicians on the website who are trained in this method. And we know through COVID, you can do stuff through telehealth. And it's not a lot of treatment. It's literally, it's often, for some people, it might be three or four sessions, for some it might be eight sessions, but it's over a period of time and it's an empowerment model and it's around understanding and listening and validating of building a new understanding of what's happening and building hope
Speaker 1
for change in the body. Pisa, we started this conversation with hope. We're ending the conversation with hope. A huge thank you to you and all of your colleagues for what you're doing and publishing research in this area. That's a coming to the studio in there. Good luck for the future. Well, thank
Speaker 2
you, because
Speaker 1
it's people like you that help get our
Speaker 2
message out.

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