One in five adults in Europe have chronic pain, and for a significant minority the pain is severely disabling and distressing for all involved. The figures don’t change across Europe; whether in Moldova, Finland or the UK.
The sudden lockdown and social distancing measures associated with the COVID-19 pandemic have had immediate economic and social consequences across Europe. Redundancy, home schooling, and working from home bring new challenges to many sections of society. However, the wider, long-term ramifications that these responses have had on individuals is a growing cause for concern. We are also starting to hear more about the far-reaching consequences the COVID-19 response could have on people’s mental and physical health; especially among those with long-term health conditions.
For example, the postponement of routine elective surgery and reductions in dedicated services for those with long-term health conditions could have a negative impact. Changes to healthcare provision could result in an increase in morbidity down the line, as delays to treatment mean some conditions worsen and become harder to manage. Increases in anxiety and depression are also being reported with the demand for mental health services, including support for front-line carers, likely to increase.
These issues are expected to be particularly felt by those with complex health conditions, such as chronic pain, which often have hard to understand needs. Pain is a common symptom of injury, illness and disease, but when chronic, it becomes a primary disease. Once established, it is hard to shift. Chronic pain does not get better spontaneously when ignored, and in fact gets worse. We know that from adolescence onwards, women disproportionately suffer more pain than men, and that later life for some can be blighted by complex pain from multiple causes.
Chronic pain and its variations are also poorly understood - and often poorly-managed - across Europe. For example, an overreliance on pharmacological treatments, such as opioids, often fails to provide adequate relief. However, the opioid crisis is really two crises. In wealthier countries, where pain management services are well-established, we are beginning to see the over-supply of medicinal opioids for non-cancer pain, leading to complex social and health problems. In other countries, the crisis is one of undersupply of opioids, meaning many people with cancer pain or pain at end of life are not benefiting from effective medicines.
Best practice approaches recognise pain as a complex condition that requires a multidisciplinary approach to effectively manage it. But how are we to deliver such treatments in the current pandemic? Some dedicated pain clinics have been temporarily suspended, and there are concerns that those with long-term painful conditions will be left with nowhere to go. Some are starting to move healthcare provision online but this brings other challenges, such as how to effectively deliver intensive multidisciplinary face-to-face pain management approaches remotely, and well as how to ensure adequate patient access.
What we also know about complex conditions, such as chronic pain, is the critical role that psychological factors have in helping people to manage their condition. For example, as well as anxiety and depression, shame and embarrassment affect those in pain, and there is potential for increased stigma amongst those with complex, hard-to-understand needs. Family members and friends provide good sources of support to those people. However, living in lockdown at home could also cause further problems, such as empathy fatigue. Social distancing, and the potential for social isolation, may well exacerbate what is already a difficult situation. With fewer treatment options available, we not only risk increasing the negative impacts on those in pain but also on those with caring responsibilities.
So, what is the solution? To start with, we need good intelligence, particularly at a European level. To fully understand how COVID-19 affects the lives of those living with chronic pain, we need to ensure that the data collected reflects the multifaceted impact that pain can have, as well allow for the exploration of known individual differences and vulnerabilities. The efficacy of traditional chronic pain management rehabilitation programmes is unlikely to dramatically improve in the short-term. Finding more accessible and preventative approaches needs to be considered.
This requires a deeper understanding of pain itself, including at a wider societal level. Some beliefs about pain can be punitive, unscientific and unhelpful. People remain very unaware of the normal psychological processes related to something as powerful and ubiquitous as pain, and it is often a revelation to them when it is explained. And health services which target people before their pain has become disabling would surely be worth considering.
Without careful planning, there is a perfect storm ahead with those with complex needs being left behind, resulting in more and more people living with persistent, intractable, and highly disabling, painful conditions. We need to ensure this does not happen, to ensure we maintain best practice services, as well as adapt and find better ways to help people across Europe manage poorly understood long-term health conditions.
- Professor Edmund Keogh is Deputy Director of the Centre for Pain Research at the University of Bath in the UK.
- Professor Christopher Eccleston is Director of the Centre for Pain Research.
- Dr Mike Osborn is a Consultant Clinical Psychologist at the Royal United Hospital in Bath.
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