12 minute read
Preserving wellbeing for the chronically ill
Chronic pain populations can be disproportionately impacted by public health restrictions during a pandemic. Consequently, it is important to maintain access to essential non-urgent support services during periods of lockdown in order to preserve wellbeing in this population, a new study recommends. ZOË ZAMBELLI reports.
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AMONG chronic pain populations, the decreased ability to self-manage pain, restricted access to healthcare and increased dependence on others are found to be associated with negative wellbeing outcomes related to sleep, anxiety and depression. A study funded by the Economic and Social Research Council examined the experiences of these individuals during recent periods of lockdown with a view to mitigating risk in future waves where possible.
There is clear evidence that selfmanagement strategies play an important role for psychological coping and management of chronic pain. These strategies include adhering to prescribed medication or physical activity regimen, identifying treatments jointly with a health practitioner, in addition to managing the impact on mood and relationships due to pain interference.
Losing the ability to self-manage or restricting healthcare access for prolonged periods may have a significant impact on wellbeing, including sleep behaviours and mental health. The pandemic brings risk and burden to chronic pain populations regarding disease management, as well as the potential to impact social and health behaviours.
Evidence also suggests that socioeconomic status (SES) may influence self-management outcomes as those with low SES may have access to fewer resources than those with high SES. Additionally, access to healthcare greatly impacts an individual’s health journey as those with chronic pain rely on a combination of assessments, diagnostics, and interventions, involving frequent interaction with the health system.
The objective of the study was to explore changes in wellbeing outcomes as related to sleep, anxiety and depression within a community sample of adults living with chronic pain between the start of the Covid-19 outbreak, pre-lockdown and during a period of lockdown in the UK.
Respondents’ chronic pain conditions were grouped into seven types, including chronic widespread pain (eg fibromyalgia; 34%), musculoskeletal (eg osteoarthritis; 37%), headache (eg chronic migraine; 10%), visceral (eg pelvic pain; 3%), neuropathic (eg trigeminal neuralgia; 15%) and other (1%). Nearly all participants reported co-existing physical health conditions (95%), and more than half reported a mental health condition (55%).
The results demonstrated that individuals who felt less dependent on others had fewer sleep problems, anxiety, and depressive symptoms compared to those who reported feeling more dependent on others for practical and emotional support during this time.
Chronic pain poses a threat to individuals’ perceived independence, and research shows the importance of retaining independence in order to carry out activities of daily living and social interactions.
Image: freepik
Recommendations
The study highlights implications related to psychosocial wellbeing, workforce and healthcare practice along with practical recommendations which should be considered in the current climate.
Firstly, it is clear that the lockdown measures implemented during the first wave
Image: freepik
The study’s findings highlight the importance of maintaining access to health and care services as part of the wider care management plan for many with chronic pain
of Covid-19 have impacted communities and support for special populations. The research shows the importance of retained independence on mental health in chronic pain populations. It is foreseen that future lockdowns would cause a social disconnection and a threat of increased loneliness. Thus, it is recommended that considerations are made for allowing social “bubbles” and social cohesion to continue in support for chronic pain communities during future public health restrictions.
Secondly, a significant proportion of the UK workforce is affected by chronic pain and disability across all sectors and skills bases who contribute greatly to the economy. It is therefore vital to ensure this portion of the workforce can continue their contribution while managing the increased risk of disease severity as a result of Covid-19. Workplace managers (supported by policies to protect workers’ rights) should carry out necessary risk assessment and ensure that individuals most at risk can contribute via adaptable working plans, whether through remote working or redeployment, before taking steps to prevent individuals from working in any capacity.
Thirdly, there is evidence that closure of non-urgent health services has impacted waitlists as they begin to reopen. It is therefore recommended that services which begin to triage backlogs of cases based on clinical need ensure referral pathways to psychological and mental health services are in place. There is evidence that mental health has suffered because of halted health and social care services and it is reasonable to assume that once financial assistance programmes come to an end (such as furlough schemes), many more will be in need of these services.
Identifying factors which could impact wellbeing in this population may help health and social care services dealing with the pandemic’s response and recovery process. Research and learnings from the Covid-19 outbreak should be used to inform policy and emergency planning responses for future pandemics. Policymakers should consult with a wide range of professionals such as healthcare, social workers and third sector workers to plan local strategies which meet individual as well as collective needs within the population.
l Zoë Zambelli is a doctoral student funded by the Economic and Social Research Council (ESRC), part of UK Research and Innovation.
Recycling can raise precious funds for BackCare
PROLONGED periods of lockdown have prompted many of us to reorganise our lifestyles. One encouraging trend is to reduce, re-use and recycle more, with the aim of a greener, more sustainable future for all of us.
BackCare is partnering Recycling for Good Causes and we are encouraging our supporters to recycle what they can to help protect our precious planet for future generations, whilst raising valuable funds to help us to help even more people who are living with back pain today. A win, win all round!
So what sort of things are we looking for? There are many items you may not have considered recycling, including unwanted gold & silver, watches, costume jewellery, banknotes & coins, foreign currency – even unchangeable UK & foreign currency, mobile phones, video cameras, digital cameras, games consoles, iPods, laptops, tablets, games & accessories, MP3 players and much more.
We have free-post labels/envelopes for your smaller items and free sacks for larger items. The more you can collect, the more cash BackCare will receive. For further information about how you can recycle more for BackCare contact: Info@backcare.org.uk or phone 0208 977 5474
Scientists weighing up the results of “retrospective” medical scientific papers in to the safety of cannabis medicine. Right: cannabis oil
Do cannabis medicines have a role in treating back and spinal pain?
Now legalised and increasingly available, cannabis medicines may offer pain management alternatives for those who are struggling with long-term back and spinal pain. Senior consultant in pain medicine, DR ANTHONY ORDMAN, discusses recent developments and the changing regulatory environment.
PERHAPS back pain is so common because our spines were designed by evolution for walking on all four limbs and supported at both ends! But we, as humans, insist on walking only on our hind limbs and sitting upright, putting much more mechanical strain on every structure in our backs than they were “designed” for. Many of us mobilise our backs through stretching and exercise rather less than we perhaps should. We also tend to be much more sedentary, and so the postural “core stability” muscles surrounding our spines can become rather less effective as “guy ropes” than they should be.
Then, as intervertebral discs become worn, and facet joints at the back of the spine become enlarged and stiff, nerve roots leaving the spine to go down the arm or leg become pinched, and spinal muscles can become painfully tight, and spines can become stiff and painful.
Often, with the right balance of rest and exercise, and simple pain medicines such as paracetamol and ibuprofen, an episode of back pain can settle down relatively quickly. But some people are not so fortunate, and pain in the spine and limbs can go on to become long-term or chronic. And there are many other people, who suffer spinal pain brought on by their long-term medical conditions, such as multiple sclerosis, inflammatory arthritis, fibromyalgia, or hypermobility and Ehlers-Danlos syndrome, who really have a very difficult time, despite the best medical treatment of the underlying medical condition itself.
Centralised pain
Modern physiotherapy and medicine can often be of great help in such circumstances. But sometimes, even in the best of pain clinics, with x-ray guided spinal injections, the best pain medicines, expert physiotherapists and clinical psychologists, acupuncture and homoeopathy, these are not enough, and we struggle to help people
rid themselves of back pain, enough to be able to enjoy life again. Often, this is because the pain has been “centralised” by changes in the nerve cells of the central nervous system.
Thinking in particular of the specialist pain medicines we have to offer, choices can be surprisingly limited, and we have to be careful not to do more harm than good. Opioids such as codeine, tramadol and morphine don’t often help after a few weeks, but continue to cause sedation, brain fog and constipation, with a high risk of dependency. Medicines such as amitriptyline used for nerve pain, low mood and poor sleep, can take away more from patients in terms of memory and alertness than they give through pain reduction. The same is so often true for gabapentin and pregabalin, and other medicines licensed for treating pain. And while we are hopeful that the new classes of pain medicines will come along soon, we can’t expect any miracles just yet.
The endo-cannabinoid system
Throughout my years of attending national and international scientific medical meetings, almost every conference seems to have had at least one lecture on the mysterious “endo-cannabinoid system”. This is a system of natural biological pathways present in all of our bodies, where nerve cells, and immune and other cells use natural “cannabinoid” substances to signal to each other, regulating bodily processes such as pain transmission, inflammation, and so on. The function of the endo-cannabinoid system seems to have to do with normalising body activity after illness or injury. The hope had always been that, very soon, the big mainstream pharmaceutical companies would find us the medicines we needed to modulate the endo-cannabinoid system to reduce pain and improve lives.
Unfortunately, this hasn’t happened, partly because the legal and regulatory frameworks of many countries have made the development of cannabinoid drugs difficult or impossible. While one or two cannabinoid medicines did become available in this country, their applications and benefits were limited. By contrast, when desperation had driven some people to try illicitly sourced cannabis for their pain, we heard reports that these were sometimes more effective than new and expensive licensed medicines. Meanwhile, in other countries, such as Canada and Israel, the legal situation was eased, as it was seen that the pharmaceutical extracts of cannabis could be helpful for those suffering long-term pain and other conditions. Then, in November 2018, regulations were slightly eased here in the UK, to allow specialist doctors to prescribe cannabis based medicines legally, for long-term conditions where conventional medical approaches had been tried or seriously considered, without benefit to the patient.
I was keen to find out for myself what cannabis medicines might have to offer patients who I could not help in other ways. I was approached by Integro Medical Clinics to see if I would take up the medical leadership role in a service that would specialise in using the new cannabis based medicines. With the partnership and support of IPS, a pharmacy expert in dispensing pharmaceutical cannabis medicines, and further study on cannabis medicine, I found myself prescribing cannabis medicines for people whose lives were on hold because of pain. Many had already tried CBD oil and found this just wasn’t enough to help, something we are seeing more and more now. But in the clinic we find that, by blending just the right amount of THC and terpenes in each individual patient’s cannabis oil or flower, we are improving patients’ nerve and inflammatory joint pain and the painful muscle spasm of spinal pain, as well as improving sleep at night, without the daytime sedation or dependency of conventional pain medicines. People can begin to get back to their work, childcare and leisure activities with a clear head and sharper memory. Then, within two or three months it becomes possible to relieve some of the burden of conventional pain medicines. The same cannabis medicines can also restore healthy sleep to patients, and lift mood which had been depressed by pain for so long. People also felt brighter and less anxious than before.
n Anthony Ordman spent 20 years working in the Pain Management Clinic of London’s Royal Free Hospital and is Past President of the Pain Medicine Section of the Royal Society of Medicine. Awarded the Fellowship of the Royal College of Physicians in 2005 in recognition of his work in Pain Medicine, Anthony is now Senior Clinical Adviser and Hon. Medical Director of Integro Medical Cannabis Clinics.
Dr Anthony Ordman
The regulatory environment
Why does NICE, the National Institute for Health and Care Excellence, not recommend cannabis medicines for treating chronic pain in the NHS?
It relies on evidence from large “double-blinded random allocation clinical trials”, which are usually so expensive and time-consuming they have to be sponsored by the large, international pharmaceutical companies.
These studies have not yet taken place. On the other hand, there are plenty of “retrospective” medical scientific papers discussing safety and effect.
In this and other ways, the NHS is not ready for cannabis medicines, except in a few limited cases. Fortunately, specialist cannabis medicine clinics have been quick to respond to the new opportunities to use cannabis carefully and safely.
Use of cannabis oils
CANNABIS oils are taken by mouth, perhaps 0.5ml, placed under the tongue or swallowed. The oil’s effect comes on gradually and, taken two or three times a day, gives benefit over many hours.
Cannabis flower, also pharmaceutical grade, and with known levels of CBD, THC and terpene content, is inhaled using a specialist medical vaporiser, which heats the flower to exactly the right temperature to activate the cannabinoids.
Vaping is safer than smoking cannabis, with or without tobacco, which we never recommend, and vaping preserves the medicinal cannabinoids which are damaged by the excess heat of smoking.
