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Pain Treatment

I start by expressing my gratitude for this opportunity to raise such an important subject, which affects the lives of millions of people in this country daily. Chronic pain affects one in seven people in every parliamentary constituency throughout the United Kingdom. Inadequately managed, conditions associated with pain can have a devastating impact on the quality of life of individuals and their families. In terms of repeated appointments, chronic pain costs the NHS the time equivalent of 800 full-time general practitioners, and it generates an incapacity benefit bill that is estimated by the Department for Work and Pensions to exceed £3.8 billion a year. The biggest cost of chronic pain is borne by employers and the wider UK economy. More than £18 billion a year is wasted in lost working days and reduced productivity. The commonest causes of chronic pain are back pain and arthritis. Other causes include headache, injury, nerve pain, vascular pain, pelvic pain, cancer and rarer forms of pain, such as complex regional pain syndrome, or reflex sympathetic dystrophy syndrome, as it is sometimes called. I applied for a debate on this subject because of a courageous constituent of mine, Trudy Lapinskis of Whittlesey, who suffers from an advanced form of RSD. She has borne and continues to bear her condition with great stoicism, but not fatalism, and has shown great determination to publicise RSD to as wide an audience as possible, in order to help other sufferers, particularly those in the early stages, when diagnosis and treatment could be so effective in improving quality of life. In Trudy’s case, early diagnosis would have avoided the severe disability that she has to live with today. This debate is by way of a tribute to her and her unstinting work on behalf of other RSD sufferers. RSD is a chronic pain disorder. Common symptoms include intense burning pain, extreme sensitivity to touch, swelling, sweating, and changes in the colour and temperature of the skin over the affected limb or body part. RSD affects the nervous system, bones, muscles, skin and circulatory system. The aetiology, or cause, of RSD is most commonly a trauma or injury to an extremity, although it can affect any part of the body. The trauma does not have to be severe. Unfortunately, something as common as a sprained ankle, a knock or even a splinter in a finger can lead to RSD, which can then become a potentially disabling and lifelong problem. In some patients, an exact cause cannot be identified. The first symptom associated with RSD is a pain that is usually described as a constant burning or deep aching pain. It progresses into severe chronic pain and swelling usually occurs in the injured extremity. At that point, the oedema is localised and the skin is very sensitive to touch, with even a slight breeze being capable of causing pain. Diminished motor function and a decrease in muscle strength are associated with the joint in the extremity. Tremors and muscle spasms can also be present. Most patients experience a significant difference in the temperature of one limb as compared with the other. Osteoporosis might be noted on bone scans and, as swelling in the injured area becomes pitted, the risk of skin infections increases. In some cases, those symptoms spread to other extremities, where no injuries have occurred, and the disorder becomes much more difficult to manage. Out of all chronic pain conditions, RSD is the most severe. According to the McGill pain index, arthritis has a pain rating of 18, a fracture a rating of 19, cancer 26 and chronic back pain 27, while incredibly, RSD has a rating of 42. RSD can affect anyone—male or female, adult or child—and at any age, but studies show that it is more common in people between the ages of 25 and 55 and is seen more frequently in women than in men. It is not more prevalent in a particular race. RSD used to be considered rare in children, but there has been a recent increase in the number of cases reported among children and teenagers. In view of all that, it is imperative that awareness should be raised among GPs and consultants, with early diagnosis and treatment encouraged, to minimise the terrible suffering brought on by the disorder. I turn to a more general analysis of the problem of pain. Back pain affects most of us. Four out of five people will experience back pain lasting for more than a day at some time in their lives. It is the nation’s leading cause of disability, with 1.1 million people disabled by it. At any one time, 430,000 people in the UK receive social security payments primarily for back pain. A recent national opinion poll showed that pain is experienced every day or on most days by one in five of the 975 people surveyed, which equates to almost 10 million people throughout Great Britain, while a further one in four people said that they had pain some days. The proportion of people with pain taking time off work has increased from 35 per cent. in a group surveyed in 2002, to 49 per cent. in 2005. Half of those questioned were depressed because of their pain and 72 per cent. were less active because of their pain, with work, household activities, family life, sex, social and leisure activities, and the enjoyment of life being affected. Pain in the elderly is common. There is much evidence that it is treated badly because the elderly are often uncomplaining, because pain is not recognised, and because doctors are frightened of using strong painkillers, especially after the Shipman inquiry. Children also suffer from chronic pain, which is under-recognised and under-treated. Unrelieved pain in childhood can lead to long-lasting effects on social and physical development, and increases the chances of lifelong pain in adulthood. Pain is the commonest presenting symptom at the first consultation with a doctor and is second in the top 10 most important symptoms listed by patients, but all too often it is ignored and thought to be unimportant. Why is that? Pain is generally regarded as a warning signal, and it is thought by doctors and lay people alike that, when the cause of the pain is discovered and treated, the pain will go away. There are acute pains that indeed behave in that way, such as appendicitis, toothache, bone fractures and infections, but chronic pain—that is, pain lasting for longer than three months—serves no useful purpose. It is usually caused by a defect in the signalling mechanisms for pain within the nervous system and is poorly understood. The patient with chronic pain is often subjected to investigation after investigation and multiple consultations, only to be told that a cause for the pain cannot be found, or that it is ““only arthritis”” and that no treatment is available. How demoralising is that? Rarer types of pain, such as complex regional pain syndrome or RSD might not be diagnosed at all, leading to long-term disability from pain, and an implication that it is all in the head. Cancer pain is dreaded by all. The cause might be known, but for about 8 per cent. of sufferers the pain is so severe that it cannot be relieved, even by large doses of morphine. What can and should be done to manage chronic pain? Sadly, chronic pain cannot be cured, but in 95 per cent. of people it can be partially relieved and managed, such that the sufferer regains control over his or her life. Health professionals in this field want pain to be designated as the fifth vital sign after pulse, blood pressure, temperature and respiratory rate, so that pain is measured whenever a patient consults a doctor or nurse and so that the level is recorded consistently when a patient is in hospital. The important first step is for the health professional to believe that the pain is real, to decide where the pain is coming from and to treat the pain, not necessarily the disease. That can be done by alternative medicine practitioners, nurses, physiotherapists and doctors. It may not be easy and may require a high level of skill and training to get it right. However, treatments will not be effective if the patient does not understand his or her pain and continues to seek a reason. Treatment includes the judicious use of drugs—not just painkillers but drugs that modify the pain signals, such as anti-epileptic drugs and antidepressants. Physical methods are also used, such as TENS—transcutaneous electrical nerve stimulation—acupuncture, injections, nerve blocks, sophisticated spinal stimulators and spinal drug therapy. An effective way of helping with control over pain is a specialised pain management programme. I am talking about a multidisciplinary approach to pain management whereby a doctor, nurse, psychologist and physiotherapist, working together over a period, help the patient to gain control over the pain. However, all that takes time, and pain management does not fit easily into the target-driven, rapid-treatment ethos of the modern NHS. The recent NOP survey shows that now 14 per cent. of patients with pain have seen a pain specialist compared with only 7 per cent. in 2002, but what of the other 86 per cent? Facilities for pain management are much more developed in the USA and parts of Europe. There is a desperate need for education of general practitioners: as undergraduates, medical students receive, on average, about four hours’ training on pain and they spend even less time on the prescribing of drugs for pain. Specialist services exist in most hospitals in the United Kingdom, but their services are stretched, and some hospital services, such as at Oxford, have been withdrawn. In Southampton, the service closed and has been relocated in primary care, and at other hospitals—for example, East Sussex—there are threats of closure. Relocating a pain service in primary care should be achieved with adequate funding and planning, not by a sudden decision to close existing services or to dispense with the appropriately trained personnel. Primary care has many priorities, and pain services are unlikely to be near the top of the list. Pain management is generally known as a Cinderella service. There have been schemes to link pain management with rehabilitation and back-to-work programmes, crossing the boundaries between the NHS, social services and the Department for Work and Pensions, but those have been sporadic, although the results have been encouraging. One scheme whereby patients with back pain were allowed to return to work part-time but retained benefits for a period proved very successful. Why are such schemes not more readily available? An individual approach is necessary; one size does not fit all. It has been estimated that 10 specialist sessions in pain management are needed for every 100,000 of population, but nowhere in the United Kingdom achieves that, and services are scarcer in the midlands and Wales. Education is needed at all levels of the health service, and many more specialist nurses, doctors, psychologists and physiotherapists are required to support properly sufferers of the most severe pain. Proper pain management is not easy and presumably does not come cheaply. Inadequate assessment and treatment of pain should be replaced by early recognition of the problem; listening to the real needs of the patient; education and more education at all levels of the health service; funding for high-quality clinical and scientific research; and adequate provision of specialist services in both primary and secondary care. This was not a specialist area of mine, although I did spend two and a half magical years as the Minister for Health in Northern Ireland. The issue crossed my desk, but I have to admit that, given all the other priorities, I never spent the time on it that I should have. Perhaps it requires a constituent with this particular problem to bring the issue to the attention of an MP before these things are brought into the wider domain. I welcome the opportunity to have the debate and to put these ideas on the table for debate. I hope that the Minister will presently answer the points that I have made. I end by paying tribute to a constituent of mine who suffers immense pain with stoicism and great bravery. She is planning a huge conference at the Methodist Central Hall in London in December and has attracted prominent speakers in this field from all parts of the world. I hope that her courage will begin to open the doors to knowledge about this condition for other pain sufferers.