Emulating countries like Australia, pain specialists in Singapore are adopting a more comprehensive framework for effectively triaging, diagnosing and treating chronic pain.
In 2020, the International Association for the Study of Pain (IASP) defined pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.
When pain persists for, or worsens over more than 12 weeks, it is referred to as chronic pain. This is to be differentiated from acute pain, where pain is caused by trauma or injury and tends to be intense and short-lived. Compared to acute pain, chronic pain can severely impact a person’s mobility, function, and diminish their quality of life.
Depending on the method used to measure pain, the prevalence of chronic pain in Asian countries varies from 7.1% to 90.8% among adults. In a Singapore study involving over 600 people, 81% experienced at least three days of migraine in a month, contributing to a total annual per capita cost of $4,900 to $14,400 depending on the type of migraine experienced. Of these costs, 82.4% was mainly attributed to absenteeism and 17.1% to healthcare costs such as consultations, medications, and hospitalization.
Dr Bernard Lee, Senior Consultant Pain Specialist and Chief Executive Officer, Singapore Paincare Center, explains, “When we feel pain, the sensory receptors in our skin send a message to our nerve fibres, in particular, A-delta fibres, and C-fibres within the spinal cord. These nerves that make up the central nervous system carry the pain signal or message to the brain, where the sensation of pain is registered, information is processed, interpreted, and subsequently acted upon.”
But not all pain is equal. The cause of chronic pain depends on the location of the pain, lifestyle factors such as sports which may predispose one to strain and injury and/or exacerbate old injury, type of work, and previous invasive procedures such as surgery.
“Pain can be considered a disease in and of itself, as it is accompanied by biological changes that involve cellular and biochemical processes. Pain is also subjective, meaning how each person perceives pain is unique. Many factors, including genetic mutations, medical conditions, and a person’s state of mind, can affect how a person feels pain and make pain feel better or worse,” says Dr Lee.
Sometimes, individuals can experience pain even without a physical or structural cause, which may be associated with psychological trauma, making the condition even more challenging to diagnose and treat.
“Generally, the sooner the root cause of pain is identified and treated, the less complex and less expensive it is to manage the condition,” adds Dr Lee.
How pain is usually treated
In Singapore and other parts of Southeast Asia, it is common practice for general practitioners (GPs) to refer the patient to a specialist of the affected area. For example, a patient whose pain is accompanied with vertigo will often be referred to an ear, nose, and throat (ENT) specialist for diagnostic scans. Often, when nothing abnormal turns up on the scans that the ENT physician can identify and treat, the patient is left to his or her own devices to manage the pain, or prescribed with treatments that may not work.
"This is not unusual, and is not the fault of the specialists either. As pain management is not taught in medical school even in high-income countries (HICs) such as Singapore, and specialists tend to be trained in conditions that fall in their area of specialty, they may not be aware of specialists who may be able to help their patient," explains Dr Lee.
There are other reasons why patients with chronic pain have inadequate management; one reason is that the focus of the physician is often on promoting rehabilitation and maximizing quality of life rather than achieving cure. In many Asian cultures, patients might not seek medical help because they expect chronic pain to be a part of life and ageing that should be endured. A recent survey study on chronic pain from China showed 24.06% of respondents did not seek medical help, and 36.79% of patients never received any treatment because they believed chronic pain is not harmful.
Compounding the issue is the lack of infrastructure or capacity to deliver non-pharmacological care in local healthcare systems, especially in the low- and middle-income countries (LMICs).
How pain specialists treat pain
This is where pain specialists come into the picture. Firstly, pain is approached as a condition in and of itself. Secondly, pain specialists view pain management with a customized, patient-centric lens, instead of a ‘one-size-fits-all’ solution. While they are aware that some chronic pain can be treated with minimally-invasive treatments, surgery may be required for some conditions.
“Pain specialists bridge the gap between surgery, and longer-term pain management approaches, such as physiotherapy and painkillers. We triage the patient and decide whether he/she should be referred to the spine doctor, neurologist, or an orthopedic doctor, or treat him/her with minimally-invasive procedures,” says Dr Lee.
“Once pain appears, it can cause other biological changes in the body that result in persistent pain even after the pain generator has been removed. Pain specialists recognize the impact of pain on the body and are equipped to address the range of factors that could contribute to pain without leaving them to chance,” he adds.
No matter what treatments are prescribed, the ultimate goal is that patients are able to lead pain-free lives.
A multi-modal, holistic approach to pain management
Australia is a country which recognizes chronic pain as a public health burden that increases the risks of mental health issues and costs the economy an estimated AUD$34 billion (US$22.51 billion) per annum. Australia published a National Pain Strategy in 2011, which outlines pain management for all Australians in alignment with the 2009 Prescription Opioid Policy published by the Royal Australasian College of Physicians.
In 2016, 254 pain medicine specialists were employed in Australia, of whom just over half worked in the private sector, while 97.2% of pain medicine specialists who completed the 2016 National Health Workforce Survey indicated they were clinicians.
“Australia adopts a multidimensional, holistic approach to pain management. Medical practitioners lead the treatment of patients with chronic pain based on their medical history, with an emphasis on multi-modal approach with non-drug techniques. The GP becomes the first-in-line of the triage and decides which specialists the patient is referred to, so there is also a drive for GPs to be trained in pain,” explains Dr Lee.
In this instance, pain management involves multiple approaches including pharmacological means such as painkillers and prescriptive drugs, minimally-invasive procedures, patient education, behavioral therapy, cognitive therapy, physical therapy, family therapy, surgery, and more.
However, because pain medicine has only been recently recognized as an independent sub-specialty, the system of pain management or pain care delivery in countries like Singapore, although advanced, is not yet adequate to meet public needs or expectations.
How can Singapore transform its approach to pain?
With the Singapore government launching the HealthierSG initiative, a greater focus on preventative care is expected in many areas, including chronic pain management, as well as the decentralization of care for chronic conditions from public institutions to communities through the mobilization of GPs.
Encouragingly, some hospitals in Singapore have begun to recognize pain as the fifth vital sign for early diagnosis upon admission of a patient, in addition to blood pressure, pulse, breathing rate, and temperature. The hope is that in time, pain will be officially incorporated into the healthcare system’s patient monitoring structure.
Dr Lee believes that in order to bridge the current gaps in pain management, more doctors and GPs must be trained in this area.
“Firstly, GPs must recognize they have not been adequately trained to help patients coming to them with persistent pain, and look for ways they can be trained in the area. This is why Singapore Paincare Center is planning to roll out a basic pain course for GPs this year. This course will be intensive, consisting of six to seven modules, at a pace of one module per month. At the end of each module and the entire course, the doctors will be evaluated using actual patients. The doctors who complete the course satisfactorily will be awarded a certificate.”
“The more GPs trained in pain management, the more options patients would have to manage their condition, and the higher the likelihood of patients suffering from chronic pain to be treated using minimally-invasive therapies,” says Dr Lee.