Last week I discussed a large epidemiological study using data from the UK Biobank to derive pain profiles: four groups of population-level profiles each thought to represent different facets of functional impairment. This study found that pain location doesn’t describe real-world, clinically-relevant differences between people with pain, and instead found that clinical variables and treatments of chronic diseases were more informative. Today, I thought it was time to consider the implications of these findings on how we ‘do healthcare.’
Healthcare systems in New Zealand, like most of the world, were established within a biomedical model. Illness is explained by ‘dysfunction’ at a lower level of organisation – and this in turn is called reductionism (see Rocca & Anjum, 2020, for a recent commentary). Reductionism kind of works, to a certain extent. It helps to see an orthopaedic surgeon if you’ve fractured something and need it putting back in place. It works well for infectious diseases. It has relevance if a person has but one health problem, and if that problem can be fixed.
It falls down when we don’t have effective cures, because then we have people still living with a chronic disease, and when they get the next health problem it can affect the previous disease. As we age, we accumulate more chronic, not completely cured diseases. It’s rare for anyone in my age-group to have only the one thing going on. People will have not only hypertension but also diabetes and osteoarthritis, possibly also depression.
Barron et al., (2024) brings this multimorbidity into clear focus. All four profiles showed overlaps, all included cardiovascular, metabolic, arthropathies, endocrine disease, depression and were being treated with similar medications. The differences in medications prescribed for pain weren’t about pain intensity, nor interference, but were associated with depression – in other words, prescribers were responding to people with low mood AND pain by prescribing opioids.
If pain location, sex, age, body mass index, and pain intensity didn’t distinguish between these four groups, and if there were so many common diseases present in all four groups, how is our health system catering to their needs?
Well, it would be nice to say that chronic pain services were the norm. That it wouldn’t matter if your pain was in your right leg, or your belly, associated with diabetes or osteoarthritis, if you were a woman, or if you were anxious about your pain, you’d get ready access to an interprofessional team who could help you with how pain is affecting your life.
It’s not.
In the media today (click) is another story of someone who feels she’s being denied effective medication (opioids in her case), by a GP who is following ‘best practice guidelines‘ in a health system that is apparently not in need of more funding. Several doctors, specialists in pain and general practice, pointed out that GP’s don’t have places to refer people with chronic pain to – with Dr Luke Bradford quoted as saying “We don’t necessarily, as GPs, have the ability to send them on to the pain clinics we’d like. Chronic pain clinics are a multidisciplinary team of anaesthetists or GP specialists, psychologists and and physios, and they’re just massively under-resourced.” Of course I’d like to add that chronic pain services don’t JUST include these professions, occupational therapists have been delivering pain self management within these teams since their early days (in the 1980’s at least) BUT the point is clear: chronic pain services are not accessible for people who really need them, they’re under-resourced, GPs don’t have the resources within their settings to do what’s needed, AND people with pain are suffering as a result of decades of siloed healthcare focusing on things we can count: the number of joints replaced; the number of stents inserted; and so on. Not on the outcomes of those replaced joints, stents in people with more than one health problem – and these people are the norm.
My blog is intended to raise awareness that by focusing on individual diseases, we can often fail to understand the cumulative and synergistic effects of various health conditions on an individual. And our most problematic pains don’t follow conventional disease demarcation lines. The most troublesome pains we know about involve neuropathic and nociplastic mechanisms. The location of pain isn’t as critical as understanding that the person with a pain problem is just as likely to also have other health conditions that add their burden in living life. Simplistic suggestions like ‘diet’ and ‘exercise’ and ‘healthy habits’ might not look the same to these people as they do to someone with only ONE health condition. And drugs don’t do a lot to change diet, exercise, and sleep patterns.
ALL behaviour change is HARD. It takes time. And when you’re attempting to make changes across many aspects of living, it’s even more difficult. Behaviour change is not just a matter of knowing WHAT to do, but HOW to integrate change into routines and habits. To navigate these changes in the context of what family members enjoy, what’s acceptable within a culture, to make changes affordable, sustainable, flexible. It’s not a matter for any single health professional to take on, nor any single person. This is a complex, collective, messy and long-lasting series of actions that will need to be sustained for life.
The paternalistic biomedical model continues to dominate healthcare service delivery. Clinicians assume that they know best for the people they treat – exercises that come in one size to fit all; advice about sleep that fails to account for chronotypes or neurodivergence or shiftwork; dietary advice that doesn’t consider culture; finger-pointing to lose weight when BMI is a poor measure of obesity especially amongst Pasific and Māori people… Lots of telling people what they should do. Not so much help available for people to make those changes in ‘lifestyle.’ And we must remember that much clinical advice is derived from studies where the research paradigm eliminates the confounds that are present in people we see clinically.
My take? Individualising healthcare requires much more sophisticated data analysis than the results of a randomised controlled trial. Along with data, clinicians need skills to help people create change in their own messy complicated life contexts. This clinical approach isn’t high tech, though we can draw on data as part of it. This is about being human, taking time, listening, and an ongoing relationship so that people are supported along the way. And we’re all likely to need that human connection as we age.
Barron, D. S., Saltoun, K., Kiesow, H., Fu, M., Cohen-Tanugi, J., Geha, P., Scheinost, D., Isaac, Z., Silbersweig, D., & Bzdok, D. (2024). Pain can’t be carved at the joints: defining function-based pain profiles and their relevance to chronic disease management in healthcare delivery design. BMC Medicine, 22(1), 594. https://doi.org/10.1186/s12916-024-03807-z
Rocca, E., & Anjum, R. L. (2020). Complexity, reductionism and the biomedical model. Rethinking causality, complexity and evidence for the unique patient: A CauseHealth resource for healthcare professionals and the clinical encounter, 75-94.