The needs of those living with long-term or chronic pain are often complex, and are influenced by every aspect of a person’s life – from previous trauma to immediate social context.

This means that management of this type of pain can be incredibly complicated. Cathy Stannard, Consultant in Complex Pain and Pain Transformation Programme Clinical Lead at One Gloucestershire, explains how the ICS is using a whole system approach, via its Living Well with Pain programme, to increase the likelihood of successful treatment for patients.

Long-term pain (including chronic and/or persistent pain) is not the same as short-term pain, for example after an injury or an operation. Short-term pain often doesn’t last long, and might only need treatment for a set period of time. These treatments are usually readily available and work well.

Although chronic pain is common, affecting nearly half of people at some point in their lives, treating it can be much more complicated, due to the large number of factors at play. While around 14% of those living with chronic pain will have distressing and/or disabling symptoms, there is very little relationship between how intense the pain feels and its underlying physical cause(s). Emotions, experiences, and social context are all factors that contribute directly to how intense the pain feels, so understanding and treating it requires an extremely holistic approach, taking multiple lifestyle factors into account.

All pain we feel is affected by how we are feeling generally, our past experience of pain, and any concerns we have about the cause. Unpleasant feelings and memories, even those not directly connected to the pain, can influence how strong it feels, whilst anxiety, depression, post-traumatic stress disorder, childhood abuse and mental health problems are also likely to worsen the experience.

When pain persists, these sorts of influences play a big role in how our brains generate pain sensations. If we’re worried about how pain might affect us in the future, our pain will feel worse. Severe pain can also occur when we can find no underlying injury, or an injury that is not usually too troublesome. All of these factors make it difficult to treat.

According to National Institute of Health and Care Excellence (NICE) guidelines for chronic pain, published in 2021, medicines are unlikely to help. The guidelines showed, however, that exercise can be helpful for most sorts of chronic pain, offering pain reduction, improved quality of life, and better physical and emotional wellbeing.

NICE has also emphasised the importance of shared decision making, and the building of trusting relationships between healthcare professionals and people with pain. It is this rounded, person-centred approach, with the aim of improving long-term pain for patients, that we are facilitating at One Gloucestershire.

Utilising the whole system approach

In Gloucestershire, we have developed an evidence-based programme, focused on exercise and improved access to mental health services, to help people with chronic pain live as well as possible.

The Living Well with Pain Programme uses a system-wide approach to bring services together effectively. The programme has been running for four and a half years and aims to develop a shared understanding of the complexity of chronic pain and the things that influence it, share evidence about the effectiveness of medical treatments, minimise harm from these treatments, help healthcare professionals build better relationships with people with pain, and develop resources that will help people to live with pain.

One project we are running is a one-year GP-practice pilot that sees a specialist substance misuse navigator assist people struggling to come off harmful medicines. This will allow us to better understand their challenges, and explore ways to give them the confidence to reduce their medicines.

The programme also involves interactive education sessions, which have reached around 700 healthcare professionals. Before the pandemic, these were delivered face-to-face, whilst more recently we have run several online sessions via Microsoft Teams. The sessions include discussions of current understanding of chronic pain and what influences it, and the treatments that have been used traditionally without success as well as exploring how we can better support people living with pain.

There are multiple other strands to the programme, too. By assessing countrywide prescribing data, we have identified everyone in the county who might be at risk from their pain medicines, and arranged for reviews to take place for the most at risk. The aim is to support patients to safely reduce or completely come off medicines that aren’t providing sufficient pain relief, with the support of their trusted primary care teams.

We have also worked with Active Gloucestershire to run pilot exercise sessions for all patients who wanted to come. The aim of the sessions is to reduce pain, and improve function, mental wellbeing and confidence. The pilots, which were delivered virtually during the pandemic, proved successful, and we are now rolling out the programme to all patients with pain in Gloucestershire in the longer-term.

As well as exercise, there is emerging evidence for the benefits of social interventions in reducing chronic pain. We offer a non-medical, arts-based self-management option to adults who might benefit, in order to improve their quality of life and increase opportunities for self-management both of pain and its associated physical, psychological and social impacts. Sessions include arts activities and online and telephone support during the lockdowns. We have also piloted a music-based intervention for young people who are living with pain.

Training our staff

The role of healthcare professionals is to use their skills to make their patients better. This can create a challenge when traditional solutions and tools are not working effectively. At One Gloucestershire we know that building trusting relationships between people with pain and healthcare professionals is the basis of good pain management, and to encourage this we have offered primary healthcare staff health coaching and motivational interviewing training. These sessions have greatly enhanced participants’ confidence in supporting those living with pain.

Our ambition is to roll out this treatment not only to all primary care (GP Practice) staff, but also to stakeholder groups in hospital settings and colleagues in social care. Pharmacists are at the forefront of the community, and we have appointed a senior pharmacy educator to work with healthcare professionals across community services and in hospitals. The ultimate aim is to help them have better conversations with their patients. This improved communication and relationship building is something that, throughout all our interventions, we are committed to facilitating as widely as we can.