Pain, and its consequent management, is a major factor in today's ambulance service, with up to 50% of patients reporting pain among their symptoms when contacting the emergency service (Hawkes-Frost, 2014). Pain management is one of the key responsibilities for all clinicians working in health care, and paramedics have a duty of care to ensure that it is managed effectively, ethically, and in line with local and national guidelines (Peate, 2011). This has been recognised by many ambulance Trusts and has led to various initiatives in order to: first, better treat the pain (through the introduction of more appropriate and more effective analgaesics), and second, be more efficient with the deployment of resources (with the introduction of specialist pain paramedics and guidelines to treat within the multi-modal model). Unfortunately, there are still large inconsistencies between the different ambulance Trusts and in the subsequent curriculums of the associated universities that supply the next generation of paramedics. This has led to a leading expert in pre-hospital analgaesia to state that there is a ‘low priority placed on pain assessment and management…for many pre- and out-of-hospital health professionals’ (Hawkes-Frost, 2014). Hence, as the ambulance service continues in its transformation from a primarily emergency care role and into the realms of community urgent care, the need to understand the biopsychosocial model and the role that paramedics play within the multi-disciplinary team has become apparent.
The biopsychosocial model
The biopsychosocial model is a term to describe the combination of three important factors that heavily influence the lives of patients suffering a disease or illness:
The biomedical model
Historically, and still ever-present today, modern medicine relies heavily on the biomedical model. This model looks to separate the body and the mind and treats the two as independent entities with little to no acknowledgement that one has an effect on the other. The biomedical approach pays lip service to the psychological and sociological implications of the illness, thereby reducing an illness into a narrow perspective and ignoring the emotional aspect of any illness and the knock-on consequences it has. Termed mind/body dualism, as proposed by Descartes in the 17th century (Descartes, 1664), the model is very focused on treating the physical symptoms that can be either seen or measured and where a drug or surgical procedure can ‘cure’ the problem. This reductionist approach treats doctors as a form of engineer working to mend a broken or dysfunctional part of the body in isolation by identifying a specific disease and applying a specific treatment for that disease. This is known as the ‘doctrine of specific aetiology’ and has been the major focus in medicine since the germ theory of disease was theorised in the 19th century (Nettleton, 2013).
We now recognise that the brain does not work in isolation, especially when in pain, and through studies looking at, and talking to, patients with chronic illnesses the major shortcoming has been the lack of emphasis placed on the person as a whole. The biomedical model ignores the psychosocial factors surrounding an individual's culture and beliefs and completely dismisses the past experiences and feelings of the patient and how this affects any treatment. We now know that pain and personal experiences do not occur in a vacuum and are in fact mediated by cultural and social structures that make a big contribution to the patient (Denny, 2009). For example, women suffering from endometriosis say that the lack of attention to their psychological and social welfare has more of a detrimental effect than the actual condition itself (Grace and MacBride-Stewart, 2007). Interviews with women suffering from endometriosis demonstrate that personal and intimate relationship difficulties have arisen and it is these that were of more concern to them than the pain (Strzempko Butt and Chesla, 2007). Another criticism with the biomedical model is its failure to involve the whole person within the socio-environmental context of illness (Nettleton et al, 2004) and how it underestimates the link of illness with personal material circumstances.
Sociological issues of pain
The sociological issue of pain builds upon the premise that no illness is suffered in isolation. In fact, the assumption is that people will rationalise what is happening to them within a social model and create a social construction that is based on their relationships, past experience and language (Leeds-Hurwitz, 2009). Therefore, for persistent pain and/or chronic illness the importance of a social constructionist approach will help to provide a better holistic treatment plan.
The social constructionist approach
The social constructionist opinion recognises the distinction between the disease (an area that the biological model focuses on) and the illness (the sociological meaning of the disease) (Eisenberg, 1977). The sociologists approach looks at how the individual makes sense of the illness and the physical and social interactions that are affected as a result (Bury, 1982). This ‘individualism’ of the disease combined with the social factors cannot, and does not, fit into the biomedical model which lends its intellect mainly to the giving of drugs to treat a specific dysfunction. Eliot Friedson's 1970 book Profession of Medicine, alongside important early sociological thinkers such as Emile Durkheim and Karl Mannheim (to name but two), laid the fundamental groundwork for recognising the social complications surrounding illness (Friedson, 1970), and states that an illness can have complications far reaching the effects of the biological state of the body and that ‘the social construction of illness’ is independent of any physical defects.
Adopting the role of the sick patient
Friedson's social construction of illness urged clinicians to not only focus on the obvious social consequences but also how the signs and symptoms will get labeled and diagnosed as a disease or illness in the first place (Friedson, 1970). This challenge to the medical model had been argued earlier in the 1960s with the science of symbolic interactionism and phenomenology, which illustrated and conceptualised the ‘moral career’ of patients and how a diagnosis may launch such a career in patienthood (Goffman, 1961). Sometimes called moral entrepreneurism, and distinct to positivitist interpretations, the role that medical sociologists claim patients adopt points to conditional processes where specific experiences and behaviours define their medical conditions (especially those that have been diagnosed) which then lend themselves to a degree of social control (Becker, 1963; Spector and Kitsuse, 1977; Conrad and Schneider, 1992). Both Gusfield (1967) and Foucault (1975) noted the shortcomings of the medical model with Gusfield stating: ‘Illness is a social designation, by no means given in the nature of medical fact’ (Gusfield, 1967), and Foucault scrutinising medical knowledge as a form of power (Foucault, 1975). Specifically, Foucault argues about the knowledge/power expression, where the knowledge of what is normal and abnormal is the principle form of power used. In short, the Foucauldian tradition explains the influence that a certain medical condition has on the behaviour and experiences of a patient, and indeed, can shape their identity to conform to the accepted role that someone with this illness should perform.
Psychological issues of pain
For many, this role will lead to other medical problems, especially psychological disorders such as depression and anxiety. These have long since been known to accompany chronic pain and long-term illness, with research showing that increased pain perception contributes to the variables seen in the development of the symptomatology of psychological disorders (Rudy et al, 1988; Turner et al, 2001; Tan et al, 2002).
Depression
There have been many studies reporting a strong link between chronic pain and depression, although research looking at the variables involved is, at best, scarce (Geerlings et al, 2002; Ferreira and Sherman, 2007). The general assumption is that pain perception, alongside cognitive behavioural traits, both play important parts in the symptomatology of chronic pain, and therefore patients suffering from more intense, more frequent, and longer lasting painful episodes are more likely to suffer severe depression (Rudy et al, 1988; Fishbain et al, 1997; Turner et al, 2001; Tan et al, 2002). Unfortunately, the prevalence of the pain/depression combination within individuals varies from between 1.5% and 87% (depending on the assessment method), and this has shown to be problematic for the effective psychological treatment of chronic pain sufferers (Wörz, 2003). This lack of treatment serves to increase the level of depression, which acts as a vicious circle that is degenerative in nature and contributes, or even exacerbates, the psychological problems encountered (Morley et al, 2002; Poole et al, 2009).
Anxiety
Tang et al (2009) addressed the issue of anxiety and pain by conducting in-depth semi-structured interviews with 60 patients from a specialist pain clinic. They describe five distinct themes that emerged from the transcripts and identified that pain preoccupation (mindfulness) and self-identity are two major components that psychologically affect chronic pain patients. They also noted that there was a difference in the mindset of patients that were anxious, or suffering from anxiety, from those that were not, and supports the use of cognitive behavioural therapy (CBT) as part of the treatment plan for pain. The findings underlined the need to treat patients as individuals due to their psychological needs and challenged the modern practice of ‘lumping’ all patients into a single group and treating everyone the same. The ‘health anxiety’ phenomenon has been found in around 50% of all chronic illness sufferers and has been shown to be a major factor in catastrophising pain and in the safety-seeking behaviour (Rode et al, 2006). These psychological reactions to the illness may unintentionally increase the mindfulness of the patients which will then affect the longer term prognosis and mental health (Clark et al, 1999; Salkovskis et al, 2003).
Catastrophising pain
Catastrophising pain is common in patients living with chronic pain, as it is with most excruciating chronic illnesses, and is a powerful influencing factor on the psychology of the individual (Jensen et al, 1991; Sullivan et al, 2001; Richardson et al, 2010). This is especially the case with endometriosis, for example (but can apply to most painful conditions), due to its cyclical nature of exacerbation every month, and the expectation that pain is coming and it is going to be ‘bad’, as indeed it is for many women. The result of catastrophising pain is the loss of the ‘patient-centered’ treatment strategy and a total reliance on the health system for all aspects of care and assurance. This serves to make the patient helpless, and with no discernible coping strategy except to look for others for help. An experiment conducted by Vowles et al (2007) looked at lower back pain and showed that those treated with instructions regarding the acceptance of their pain displayed improvements in physical functioning when compared to patients left to their own devices. Indeed, Vowles has conducted several experiments looking at acceptance strategies for coping with pain and how the psychological cannot be separated from the physical, and those patients who received good psychological aid showed improved process of acceptance and, as a result, improved quality of life (Vowles et al, 2008a; 2008b; 2009).
The multi-disciplinary team
The increased reliance upon the ambulance service to provide an urgent care service places an emphasis on better education and referral options for paramedics in order to provide a more holistic and efficient approach to managing such patients. The ‘key principles of care’, as cited by the National Institute for Health and Care Excellence (NICE) guidelines, highlights the importance of a multi-disciplinary team when managing the long-term health and mental well-being of patients; and as the paramedic profession is now a part of this team, the need for better guidance, education and research into treatments of pain in the pre-hospital setting is apparent (NICE, 2013).
Multi-modal pain management strategy
As an acceptance of the current state of affairs, the Royal College of Emergency Medicine has issued a guideline for the management of pain and have offered recommendations for drug administration within a multi-modal approach strategy (France et al, 2014). Supported by data from hospital and post-hospital environments, it is proven that by combining analgaesics with different mechanisms of action and a focus on the psychosocial aspects of pain, patients will receive better acute analgaesia, have a better healing outcome, which in turn provides for better long-term health and save the NHS money. With this in mind, and by observing the practices from other countries, an emphasis on adopting a multi-modal approach to pain management comprising of analgesics with different modes of action is now best practice (Association of Ambulance Chief Executives, 2013).
The strategy encourages the administration of different analgaesics that act with different mechanisms of action, the non-pharmacological treatment of pain through the expertise of physiotherapists, and the specialist services of doctors and psychologists that work within a pain clinic that can treat the expectations of patients and the social factors associated with pain.
Patient-centered approach
Illnesses have both a medical and a psychological aspect that needs to be addressed, but often are treated in isolation, and with greater vigour placed upon the medical model. Of course the medical aspects of illness should not be ignored, and this is especially the case with painful conditions, but if a better patient experience and outcome is to be achieved then psychosocial treatments need to run alongside the biomedical treatments. It is well recognised that chronic pain sufferers will experience good and bad days, and that they need to be educated to not ‘over-do’ things on the good days and ‘learn to cope’ with the bad days. Education of the patient will empower them to know that the bad days will pass and by having that type of mindset they will catastrophise the pain less and feel better as a result.
Use of pain clinics and a pain pathway
As is the case for most other illnesses and diseases (especially chronic conditions) the use of specialists provides the best possible outcome for patients and the NHS. The introduction of a pain pathway into the ambulance service will reduce the need for A&E admissions and quicken the time to treatment from a specialist in the field of pain. This should reduce side effects, such as repeated calls for help, prolonged suffering, the onset of pain induced depression and anxiety, and other medical psychological and sociological issues that arise from being in pain.
Appropriate treatment
So the big question to be asked is: ‘As part of a multi-disciplinary team, what is the appropriate treatment for this specific condition?’ If we are to accept that not all painful conditions (including an acute flare-up of certain chronic conditions) require A&E admission, then guidelines, education, pathways, and new analgaesics need to be a part of the conversation regarding the forward movement of the paramedic profession in how best to serve patients in pain. These new skills and options will give paramedics the confidence to make the appropriate choice for treatment for each individual case, and cement the profession as part of a fully-inclusive multi-disciplinary team. In addition it will address the issues raised by Jones and Machen (2003) regarding the paramedics' perspective of pre-hospital pain management, and the fears and misconceptions that are held.
Implications for paramedic practice
The implication for paramedics is to:
This culture change in paramedic practice will save money on secondary costs for the NHS, save money for the ambulance service on repeat calls for the same problem, and will also offer the patient the correct and appropriate treatment for their condition. The patient-centered approach gives the power back to the patient which will help to balance the psychological and sociological issues that can arise thereof, and the referral to a pain specialist will quicken the time to appropriate treatment and halt the deterioration into depression and anxiety.
Conclusions
As is often written, and described perfectly by Bourke, pain is not experienced in isolation or in private but instead is an inherently social event that affects all aspects of a person's being (Bourke, 2014). The medical model used by many health professionals ignores the psychological and sociological factors until they have become a big enough problem where they have now manifested into a new condition or disorder. This, alongside the gender and cultural issues, adds to the distress of the patient and to the people that are left to care for them in their time of need. All this belies a culture of pain where recognition and treatments of painful conditions bias heavily on some diseases while ignoring or dismissing others. This helps to shape the self-identity of a sufferer, which is based on experiences, and can force the patients to assume the ‘role’ of the sick person and behave in accordance to that perceived role. The patients will also form an opinion and attitude towards healthcare institutions and the professionals that work within their medical structure. This can, in the eyes of patients, make the individuals complicit with the neglect of painful and life-altering conditions that may permanently change the patient's focus and aspirations for the future, and disconnect the patient from the people that are there to help them.