It was ten years ago, in September 2010, that representatives of the International Association for the Study of Pain (IASP) from sixty-two countries signed the Declaration of Montreal. This Declaration set out to change the current view of pain to one “that access to pain management is a “fundamental human right”, by “recognizing the intrinsic dignity of all persons and that withholding of pain treatment is profoundly wrong, leading to unnecessary suffering which is harmful”.(1)
Since then, there has been “increased awareness of the biopsychosocial model of pain”(2), particularly in terms of the management of chronic pain.
The biopsychosocial model has led to the development of the most therapeutic and cost-effective interdisciplinary pain management programs and makes it far more likely for the chronic pain patient to regain function and experience vast improvements in quality of life.”(3)
Gatchel and Howard, 2018
Another positive development has been in patient-centered chronic pain care, which “underscores engagement of patients in decision-making, consideration of patients’ emotions, keeping patients informed, and motivating patient self-management. These approaches promote better patient-provider communication and improve patient outcomes”.(4)
In 2019, the medical journal Canadian Family Physician stated that: “Interventions should equip patients with pain self-management skills and better access to nonpharmacologic options to empower their pain management and improve quality of life”(5)
Despite these advances in the literature, there remain significant gaps in access to specialist pain management – particularly to patient-centred chronic pain care – around the world.
There have also been negative outcomes of the Declaration of Montreal for patients living with pain. The most well-known, of course, has been the impact of opioids. These medications were falsely marketed – and approved by governments – as being non-addictive products, so became an attractive option for physicians seeking to help their patients. Only years later did it become apparent that these products could indeed trigger addiction.
None of the current opioid ‘crisis’ or ‘epidemic’, depending on your geographical area, was caused by patients themselves; clinicians were enticed to prescribe these products under false pretences, usually with the best of intentions. Yet it has been the patients, rather than the prescribers, who have largely borne the brunt of blame for the opioid epidemic.(6)
And although “there’s no doubt that the opioid epidemic is a public health crisis… it has led to a heightened atmosphere of distrust surrounding patients’ reports of pain – both chronic and acute – that especially affects certain patients: women, people of color, people with low incomes.”(7)
Government actions to curb the misuse of opioid medications also targeted their legitimate use within specialist pain management clinics. This left a subgroup of patients without access to a controlled substance which had previously been deemed beneficial to them.
The opioid crisis (now actually a Fentanyl crisis in North America) also increased the stigmatization of chronic pain patients:
People living with pain have limited access to the services they require and often face stigma and undue suffering as a result of their condition. This stigma often intersects with other forms of discrimination related to poverty, housing and employment instability, mental illness, race and ethnicity, and other factors further complicating the challenge of living with pain.”(8)
Canadian Pain Task Force, 2019
This additional burden of stigma due to the opioid crisis, placed on patients, means that now more than ever “pain management discussions between patient and provider can be stressful to navigate and greatly impact the care received.”(9)
In 2010, the year of the Declaration of Montreal, Ronald Melzack wrote that chronic pain “is now a major challenge to medicine, psychology, and all the other health sciences and professions… We must also teach patients to communicate about their pain, and inform them that they have a right to freedom from pain.”(10)
Several years later, the Director of the Alan Edwards Pain Management Unit – the pain clinic founded by Dr. Melzack at the McGill University Health Centre (MUHC) in the 1970s – provided an update that remains accurate today:
chronic pain is far from being conquered, and our ability to cure, and even to properly treat patients suffering from it, is still limited.
Shir, 2015
Our limited abilities are frustrating not only for patients.
We, the clinicians, are almost equally frustrated because of the growing gap between the substantial scientific advancements in chronic pain research and our limited capacity to heal it.”(11)
It’s my hope that the next decade will see pain research being translated into improved clinical care of people in pain, into better pain management options for those of us living with chronic pain conditions.
As always, thanks so much for stopping by. I hope that you and your loved ones are doing well, despite this strange pandemic era in which we are all currently living, and that you’re taking time to look after yourself. Feel free to reach out over on Instagram or Twitter; I’ve had to disable the comments here on the blog as managing them became too much for my mild cognitive impairment to handle.
References
(1) International Association for the Study of Pain (IASP). Declaration of Montreal. 03 Sep 2010. Approved 28 Oct 2010. Online:
https://www.iasp-pain.org/DeclarationofMontreal?navItemNumber=582
(2) Darnall, Beth D et al. “Pain Psychology and the Biopsychosocial Model of Pain Treatment: Ethical Imperatives and Social Responsibility.” Pain medicine (Malden, Mass.) vol. 18,8 (2017): 1413-1415. doi:10.1093/pm/pnw166
(3) Robert J. Gatchel and Krista J. Howard. The Biopsychosocial Approach. Practical Pain Management. 2018. Volume 8, Issue 4. Online:
https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach
(4) Haverfield, Marie C et al. “Patient-Centered Pain Management Communication from the Patient Perspective.” Journal of general internal medicine vol. 33,8 (2018): 1374-1380. doi:10.1007/s11606-018-4490-y
(5) Canada’s hidden opioid crisis: the health care system’s inability to manage high-dose opioid patients. Hance Clarke, James Bao, Aliza Weinrib, Ruth E. Dubin, Meldon Kahan. Canadian Family Physician Sep 2019, 65 (9) 612-614. Online:
https://www.cfp.ca/content/65/9/612?rss=1
(6) Hirsch, Ronald. “The Opioid Epidemic: It’s Time to Place Blame Where It Belongs.” Missouri medicine vol. 114,2 (2017): 82-90.
(7) Maya Dusenbery. Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick. Part 3, Chapter 5; Chronic Pain: “Pain is Real When You Get Other People to Believe It”; p 192. HarperOne (HarperCollins Books). Original ed 2018; paperback 2019. New York, NY, USA. ISBN 978-0-06-247083-6.
(8) Canadian Pain Task Force (Health Canada). Chronic Pain in Canada: Laying a Foundation for Action. Report. Jun 2019. ISBN: 978-0-660-31747-2. Online:
https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019/canadian-pain-task-force-June-2019-report-en.pdf
(9) Haverfield, Marie C et al. “Patient-Centered Pain Management Communication from the Patient Perspective.” Journal of general internal medicine vol. 33,8 (2018): 1374-1380. doi:10.1007/s11606-018-4490-y
(10) Ronald Melzack, in Clinical Pain Management: A Practical Guide (Eds Mary E. Lynch, Kenneth D. Craig, and Philip W.H. Peng). Foreword (2010), page xii. 2011. Blackwell Publishing Ltd. (Wiley-Blackwell; John Wiley & Sons, Ltd.) Chichester, West Sussex, England. ISBN 978-1-4444-3069-4.
(11) Yoram Shir; in Marie-Josée Rivard with Yoram Shir (Foreword) and Denis Gingras. Transl: Barbara Sandilands. Pain: From Suffering to Feeling Better (Your Health). Pages 11-12. Les Éditions du Trécarré (Groupe Librex Inc). Paperback. 2015 (original French version; La douleur : de la soufrance au mieux-être). Montreal, Canada.