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Outsmarting pain

Pain medicine applies a whole-person approach to a localised problem

Persistent pain is a complex and multidimensional condition, so the solution should also be multidimensional, say doctors who specialise in pain medicine.

Pain medicine was only recognised as a specialty in 2005, and like all young disciplines, it strives to embrace new approaches. For pain specialists, that involves strongly endorsing the  “whole person” medical movement.

The term may have New Age overtones, but for pain medicine specialists, it means looking not just at somatic or “body-based” causes of pain, but also exploring the social and psychological aspects that are contributing to the pain.

“Western medicine teaches physicians to avoid those things, so pain medicine is not everyone’s cup of tea”, says Associate Professor Milton Cohen, who is based at St Vincent’s Clinic in Sydney.

However it’s because pain has not been well managed in traditional medical settings that there is a need for a dedicated specialty, he says.

Usually, when people suffer from severe and persistent pain, it is not enough to just address an underlying medical problem. Other conditions often accompany the pain, which can magnify the problem and hamper recovery.

For instance, prolonged periods of inactivity and emotional disorders such as depression often accompany chronic pain.

“Pain is such an underdiscussed issue in the medical field”, says Professor Cohen. “Conventionally most medical specialties have a very biomedical focus. In chronic pain, there is a large psychological dimension”, he adds.

“There is also a misconception that chronic pain can be easily cured, and that it’s just a matter of finding and ‘fixing’ the broken part. Another misconception is that a drug or procedure will cure it, and that’s not the case either.”

Professor Cohen says it was this complexity that drew him to the specialty. “ It involves addressing a challenging problem that is highly prevalent in the community but not well understood and therefore not very well treated”, he says.

However, he says that because of the emphasis on psychosocial issues, he wouldn’t necessarily recommend the specialty to a junior doctor.

“You approach this after you’ve done other training, for the reason that it requires a fair bit of experience and maturity to appreciate why there is a need for specific expertise in pain medicine. I would recommend it to early mid-career doctors who have already chosen a path of practice and find pain an interesting area.”

The Faculty of Pain Medicine is a faculty of the Australian & New Zealand College of Anaesthetists (ANZCA) but attracts trainees from various other specialties (see training box, below).

Pain management strategies once focused on acute pain following trauma or an operation, as well as cancer pain. The pain medicine specialty, however, evolved out of the need to help the large number of patients suffering from severe, chronic pain who had nowhere to turn for treatment.

Over the past decade, dedicated pain clinics staffed with both pain medicine specialists and allied health practitioners such as physiotherapists, occupational therapists and psychologists have emerged.

These non-medical specialists play a crucial role in the treatment of pain, according to Professor Julia Fleming, the director of the Professor Tess Cramond Multidisciplinary Pain Centre at Royal Brisbane and Women’s Hospital.

“When pain becomes persistent, you not only have to deal with that pain, but also a number of other issues that may result in poor quality of life, like disruption to your normal daily activities, the impact on your family and friends, your ability to work and your perception of yourself and your role in society. That often leads to anger, frustration and despair about the future”, she says.

Trainees learn about managing acute pain, cancer pain, chronic non-cancer pain, as well as trying to decrease the progression from acute pain to persistent pain.

Dr Geoffrey Speldewinde, who works in private practice in Canberra at Capital Rehabilitation and Pain Management Centre, says pain medicine specialists are trained to always look at the person’s complaint in the context of that person and their life story, an approach that could also be useful in other specialties.

“In pain management we comfortably address psychology and social factors in someone’s biological pain state as we do in addressing probable physical pathology. We have much to offer our colleagues who manage other chronic health conditions such as diabetes, heart failure or asthma who don’t so readily acquiesce to the significance of those [factors] in illness management”, he says.

Training as a pain medicine specialist

Pain medicine is an “add-on” specialist degree, which means trainees have to have completed, or be training toward, a specialist qualification in a participating specialty, such as anaesthesia, surgery, psychiatry or rehabilitation medicine.

Entry into training is also open to Fellows of the Royal Australian (or New Zealand) College of General Practitioners or another faculty or chapter of one of the colleges for the participating specialties mentioned above.

Training is overseen by the Faculty of Pain Medicine of the ANZCA, and involves 1–2 years of supervised training (dependent on experience) in an accredited multidisciplinary pain centre.

The faculty evolved out of collaboration of five participating bodies: ANZCA, the Royal Australasian College of Physicians, the Royal Australasian College of Surgeons, the Royal Australian and New Zealand College of Psychiatrists and the Australasian Faculty of Rehabilitation Medicine.