Friends recently sent us, as lockdown entertainment, the boxed set of a BBC series called A Very Peculiar Practice° which may be familiar to many. A satire set in a supremely dysfunctional university practice, it covers many of the challenges and personalities seen in primary care. The second episode has a truly terrifying depiction of a consultation where the patient, aptly named Professor Furie, wants a prescription for an amphetamine-like stimulant and the doctor is reluctant to prescribe it. Despite using textbook consultation techniques and attempting to explore the underlying concerns and issues relating to the request, the doctor is bullied into prescribing against their better judgement and left anxious and scarred by the interaction.
It may not be possible to reduce the pain experienced by many patients.
This approach has also been advocated recently by a Channel 4 programme, How to Beat Pain. Individuals living with a variety of problems such as migraine, rheumatoid arthritis, fibromyalgia and chronic headache were allocated to a series of different programmes to try alternative methods of pain management and their efficacy evaluated in a discussion at the end of the programme. Interventions used included acupuncture, cold open water swimming, meditation and tai chi. Some found this a very helpful process, but it was difficult to see how most could participate in activities such as cold water, open air swimming and so the applicability of some of these techniques appeared limited.
It is true that there is widespread use of ineffective and addictive pain medication of questionable benefit.
The issues regarding patient access to psychological therapies, acupuncture and exercise for chronic pain syndromes are significant, and for many a group-based approach may be challenging in view of the nature of the underlying traumas that need to be addressed. Bessel van der Kolk describes some of the predisposing traumatic events that may lead to complex pain syndromes in his excellent book, The Body Keeps the Score, and illustrates the sophistication and long-term nature of some of the supportive therapies required.2 For those who are still consulting in 10-minute aliquots in the post COVID environment, applying these new guidelines may well prove problematic. Many may be faced with their own Professor Furie experience, and it is worth watching this enactment of a difficult prescribing consultation and taking time to reflect on how to manage this negotiation in light of the new guidance.
1. National Institute for Clinical Excellence. Chronic Pain: Assessment and Management (in development) https://www.nice.org.uk/guidance/indevelopment/gid-ng10069/consultation/html-content-2 (accessed 16/8/20)
2. Van der Kolk, B. The Body Keeps the Score. Mind, Brain and Body in the Transformation of Trauma. Penguin 2015