Time to Take Chronic Pain Seriously

Prof. Dr. Oleg Ilyinski commemorates the 100th birthday of Dr. John J. Bonica, the founder of pain medicine, by exploring the advancements in our understanding of chronic pain.

Introduction

Chronic pain, particularly spinal pain, affects millions of people worldwide. In Europe, one in five individuals lives with chronic pain. In Ireland, this figure ranges from 13% to 18% of the population, highlighting the significant impact of this often-overlooked condition. Public health discussions tend to center on cardiovascular diseases and cancer, as these are the primary causes of death in Western society. Chronic pain, while not directly life-threatening, can severely diminish a person's quality of life and has long been under-recognised as a result. I once treated a patient who endured over six years of debilitating central neuropathic facial pain following two intracranial haemorrhages and a craniotomy. When I acknowledged her strength in recovering so well, she gave a faint, bittersweet smile and said:

International studies

TChronic pain has long been overlooked, partly due to limited understanding and insufficient medical education in the field. However, developed countries could no longer ignore its growing impact, especially as the economic burden continued to rise. According to Andersson G., in The Lancet (1999), the estimated cost of back pain alone in the UK reached approximately £12.3 billion. Back pain remains the second leading cause of sick leave across Europe. In 2006, a landmark study titled "Survey of Chronic Pain in Europe: Prevalence, Impact on Daily Life, and Treatment" by H. Breivik et al., published in the European Journal of Pain, provided crucial insights. The study included over 46,000 participants from 15 European countries and Israel. It revealed that 19% of respondents had experienced pain for more than six months, with frequent episodes several times a week. During their most recent pain episode, participants reported an average pain score of 5 out of 10. Among those over 70, one-third reported living with chronic pain. The survey further highlighted the severity of these experiences: 66% of respondents reported moderate pain, scoring between 5 and 7 out of 10, while 34% described their pain as severe, with scores between 8 and 10. Pain patterns varied, with 54% experiencing intermittent pain and 46% living with constant pain. Alarmingly, nearly 60% of respondents had endured chronic pain for periods ranging from two to fifteen years. Chronic pain significantly affects quality of life. In the study, 21% of participants were diagnosed with reactive depression linked to their pain. The impact on employment was equally concerning: 19% of chronic pain sufferers had lost their jobs due to their condition. Additionally, 61% reported a significantly reduced ability to work, with some unable to work at all. Thirteen percent had to change careers entirely to manage their pain. For many, medical support became essential, with two-thirds of respondents visiting their physician between two and nine times over a six-month period. A similar study conducted in the United States and published in the Journal of Pain in November 2010 involved 27,035 respondents. The findings mirrored many of the trends observed in Europe. Approximately 31% of participants reported chronic pain, with a higher prevalence among women (34.3%) than men (26.7%). As with the European study, prevalence increased with age. The research indicated that 8.1% of the general population experienced chronic lower back pain, while 3.9% lived with osteoarthritis. Together, these studies underscore the widespread nature of chronic pain and its profound impact on individuals' lives, healthcare systems, and economies across the globe.

Modern Practice

Modern pain management relies on a multidisciplinary approach, bringing together specialists such as spinal surgeons, rheumatologists, neurologists, and orthopaedic surgeons. This collaborative effort allows for a comprehensive assessment to identify and treat any potentially reversible causes of pain. When a cure is not possible—particularly in cases of persistent neuropathic pain, where pain itself becomes a disease—our focus shifts to finding the most effective and personalised management strategies to enhance the patient's quality of life. These strategies may include optimised pharmacotherapy, targeted injections using X-ray guidance, radiofrequency denervation with heat lesioning, pulsed radiofrequency treatment, platelet-rich plasma (PRP) injections, and a variety of electrical neuromodulation therapies, including implantable neurostimulators. These treatments aim to stabilise the condition enough for patients to participate in rehabilitation programs led by pain clinic physiotherapists who have specialised expertise in chronic pain. Additionally, clinical psychologists provide cognitive behavioral therapy (CBT), guidance on pacing activities, and support in developing ‘return to work’ plans where needed. European studies have revealed significant gaps in the treatment of chronic pain. Up to one-third of patients reported receiving no treatment at all, while half of all pain sufferers relied regularly on non-prescription analgesics. Alarmingly, 55% admitted to the uncontrolled use of NSAIDs (non-steroidal anti-inflammatory drugs). Research from the late 1990s indicated that these medications contributed to approximately 400 deaths annually in the UK and up to 7,000 deaths per year in the US due to gastrointestinal complications like GI bleeding and, less frequently, perforation. Among pain patients, 13% reported using weak, over-the-counter opioids, while two-thirds were prescribed medication by a family doctor. Within this group, 44% were taking NSAIDs, 23% relied on weak opioids, and 5% were on strong opioids. Despite these efforts, 40% of respondents reported that their pain remained inadequately managed. Perhaps the most striking finding was that, despite the existence of specialised pain clinics across the studied countries, only 2% of chronic pain sufferers were receiving care from pain management specialists. This highlights the ongoing need for greater awareness, education, and access to specialised care in the field of chronic pain management.

Conclusion

Adequate pain management and the relief of severe pain should be recognised as a fundamental human right. Despite advancements in the field, we remain far from answering many critical questions and continue to face significant challenges as countless patients live with chronic pain. However, modern treatments and therapies must be made accessible to everyone suffering from these conditions. It is our ethical responsibility to alleviate pain and reduce suffering. Improving medical education at all levels—undergraduate, postgraduate, and through ongoing professional development—is essential to enhance awareness and understanding of chronic pain. Additionally, raising public awareness about this issue can foster greater societal support for the development and accessibility of specialised pain management services.