Challenges of managing chronic pain
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j741 (Published 17 February 2017) Cite this as: BMJ 2017;356:j741
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Mao’s editorial about challenges of managing chronic pain called for “considering integrative approaches such as acupuncture” citing a “survey of selected physician views” and the new guideline from the American College of Physicians.(1, see 9 in 1) This deserves strong comment.
First, “integrative medicine” belongs to a long list of oxymorons (eg. complementary and alternative medicine, holistic medicine, natural medicine, unorthodox medicine, fringe medicine, unconventional medicine, new age medicine): these interchangeable practices have no relation with modern medicine. Evidence Based Medicine uses evidence from well-designed and conducted research to improve decisions by individual physicians about individual patients.)
Second, the National Institute for Health and Care Excellence (NICE) final guidance specifically recommended acupuncture not be used for managing low back pain as evidence is lacking.(https://www.nice.org.uk/guidance/ng59) Indeed, effects after acupuncture lack clinical relevance and are undistinguishable from bias. Prescribing poking with needles on non-existing meridians described in antiquity Era is an irrational superstition that a 1822 decree from the emperor of China excluded from the Imperial Medical Institute.(2) This decree did not precluded the Zhejiang provincial hospital of traditional chinese medicine to infect 5 persons with HIV using needles that had not been properly sterilized.(South China Morning Post, Feb 9, 2017. http://www.scmp.com/news/article/2069424/least-five-infected-hiv-after-d...
Mao subtitled his editorial ‘start by ensuring realistic expectations’ but gave faith in weird practices. Patients deserve truthful explanations and need reassurance to promote autonomy. Last, there is accumulating robust evidence that cognitive behavioral therapies, a term absent from Mao’s editorial, provide prolonged clinically relevant decrease in pain and functional limitations.(3,4)
1 Mao J. Challenges of managing chronic pain. BMJ 2017;356:j741.
2 White A, Ernst E. A brief history of acupuncture. Rheumatology (Oxford) 2004);43 : 662-663.
3 Lamb SE, Mistry D, Lall R et al. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet 2010;375:916-23
4 Cherkin DC, Sherman KJ, Balderson BH et al. Two-year follow-up of a randomized clinical trial of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care for chronic low back pain. JAMA 2017:317:642-3.
Competing interests: AB signed the complaint, addressed to the UK Committee of Advertising Practice, the body with responsibility for the regulation of UK-based online advertisements, against the British Acupuncture Council & over 400 UK acupuncture websites for misleading advertising claims.(http://www.scienceinmedicine.org.au/images/pdf/ukasaletter.pdf).
Communicating uncertain greys is vital
I certainly agree with the authors that chronic pain represents a significant burden and that expectation management is a vital component of treatment. Indeed a vital part of expectation management is to adequately educate patients as to several key flaws in the Descartian model of understanding pain which continue to be dangerously propagated by professionals and non-professionals alike. The fact that peripheral structure is a poor predictor of pain severity is not unique to chronic pain; it is similarly reflected in acute pain. While central factors have also been strongly linked with the severity of acute pain (1,2). While numerous studies have demonstrated that the severity of acute pain predicts the likelihood of developing chronic pain (3,4). It is unsurprising that peripheral structure is a poor predictor of pain severity as pain is a subjective phenomenon, hence why the placebo and nocebo effects are so very powerful in influencing acute pain (5,6). Acute and chronic pain are not so different in my opinion; indeed it may actually be harmful to not communicate these greyer uncertainties to patients as it can lead to more negative stigma being attached to ‘chronic’ pain, I think the same principle can be applied to the rather arbitrary and woolly definitions of ‘neuropathic’ and ‘chronic regional pain syndromes’. Good communication, education, relationships and expectation management are vital in managing all patients with any form of pain; and as part of this strategy it is vital that the medicalisation of an entirely subjective phenomenon with certain rather unhelpful stigmatising non evidence based distinctions and definitions can have unintended harms if they are poorly communicated to patients.
1. Keogh E, Book K, Thomas J, Giddins G, Eccleston C. Predicting pain and disability in patients with hand fractures: comparing pain anxiety, anxiety sensitivity and pain catastrophizing. European journal of pain (London, England). Apr 2010;14(4):446-451.
2. Borges NdC, Pereira LV, de Moura LA, Silva TC, Pedroso CF. Predictors for Moderate to Severe Acute Postoperative Pain after Cesarean Section. Pain Research & Management.
3. Fassoulaki A, Melemeni A, Staikou C, Triga A, Sarantopoulos C. Acute postoperative pain predicts chronic pain and long-term analgesic requirements after breast surgery for cancer. Acta anaesthesiologica Belgica. 2008;59(4):241-248.
4. Eisenach JC, Pan PH, Smiley R, Lavand'homme P, Landau R, Houle TT. Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain. Nov 15 2008;140(1):87-94.
5. Bingel U, Wanigasekera V, Wiech K, et al. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Science translational medicine. Feb 16 2011;3(70):70ra14.
6. Enck P, Benedetti F, Schedlowski M. New insights into the placebo and nocebo responses. Neuron. Jul 31 2008;59(2):195-206.
Competing interests: No competing interests