Chronic pain accounts for 20% of physician visits worldwide (Treede et al., 2015). The ABC recently reporting that 3.4 million Australian people have chronic pain and are waiting between 12 months and five years for an appointment at a public pain clinic (Chen & Robinson, 2020). This has been pushed to breaking point with the recent restriction of prescribing opioids along with the coronavirus pandemic (Chen & Robinson, 2020; TGA, 2020). The concept of access to pain management as a human right has gained considerable traction in recent years, with the UN adopting new standards and responsibilities for participating countries (Brennan et al., 2019; Frenkel & Swartz, 2017; Vos et al., 2017). So, whilst a national action plan is currently being prepared for state and territory ministers, the importance of studying the nuances of chronic pain management from an equity perspective is prescient.
Before I define persistent and chronic pain, I will first outline Foucault’s concept of biopolitics. Biopolitics provides a way of contextualising the authoritative domains of medical knowledges and how they are taken up by individuals, this is important in contrasting chronic and persistent pain. I then assert that the current roll-out of persistent pain treatment, slow as it may be, does not adequately address the nuanced cognitions of marginalised groups. I first describe this in terms of the social determinants of their pain and then in terms of the stigmatisation they often experience in the health care system. I then argue for the importance of research in the experiences of marginalised people doing public pain clinics, so that when others do receive attention, it is more appropriate to their needs.
Biopolitics is the “political process of controlling the bodies of individuals” (Fernandes et al., 2016, p.193). Before the nineteenth century pain was inflicted by a sovereign power through public displays of torture and corporal punishment to enforce social control. Foucault’s major contribution was to observe how this radically changed in the nineteenth century with the birth of disciplinary power (Foucault, 1991). Psychology, medicine, education all emerged as professional disciplines to cure pain and disease and ensure the productivity of the emergent industrial order. It became the responsibility of the individual to look after their body in order to be healthy and productive. People were taught new cultural norms of acceptability and how to cleanse, exercise and medicate themselves appropriately. The body became “simultaneously subdued and strengthened” (Foucault, 1991, p.194). In this domestication of the body of neoliberalism we are not simply talking about coercive power; biopolitics is internalised by a self-governing subject (Fernandes et al., 2016).
Persistent pain is a new biopolitical way of managing bodies in pain.1 Most people still think of pain as biologically anchored and under the sole domain of medical authorities. Either acute, that is directly relating to tissue damage or inflammation, or chronic, whereby the underlying pathology is not resolved, and the pain continues. Persistent pain is the new scientific discourse that pain lasting longer than three months beyond expected tissue recovery is primarily influenced by danger cognitions and psychosocial determinants (IASP, 2020; Moseley & Butler, 2017a). With the restraints on opioid prescribing and lack of evidence of biological determinants, most chronic pain is thus moving to the sphere of psychological and social authorities (see, Harris, 2016). I use the term chronic where cognitions of authors or subjects are still in the biological biopolitic, and persistent where they are in the psychosocial.
The new approach for persistent pain is a differential diagnosis and elimination of possible biological factors, then pain science education, re-appraisal of cognitions and individualised behavioural strategies (Moseley, 2010; Moseley & Butler, 2017b). Psychosocial education and Cognitive Behavioural Therapy (CBT) is becoming the gold standard for persistent pain treatment and the bread and butter of public pain clinics (Moseley & Butler, 2015; Richmond et al., 2015; Watson et al., 2019).
What is emerging from the literature, however, is the hypothesis that certain cognitions are harder to shift for different social groups. Advantaged and well-resourced members of society are willing and able to reframe their chronic pain as persistent. Marginalised participants who have experienced social hardship or structural injustice are less able. Further, some of this injustice has been inflicted by the health system. In other words, the danger cognitions may be present in relation to the system itself.
First, the main cognition addressed in pain management clinics is the concept of pain catastrophising. Pain catastrophising is the tendency to exaggerate the experience of pain in communication, feel hopeless and ruminate excessively about the implications of pain (Leung, 2012; Moseley & Butler, 2017a; Petrini & Arendt-Nielsen, 2020). Research with marginalised groups suggests that catastrophising has various determinants not reducible to blanket education and CBT delivery. A large study, with complex multivariate modelling, found that perceived injustice is a stronger determinant in life satisfaction than pain catastrophising (Sturgeon et al., 2017). A pilot study looking at perceived childhood neglect as a contributor to perceived injustice found a significant correlation (Ziadni et al., 2020). A recent study in the United States identified a strong correlation between black participants who identified with the perceived injustice category also had much higher pain intensity than white participants who did not (Trost et al., 2019). 2 There are also neurobiological theories proposing impaired pain regulation in people who have experienced trauma early in life (Asmundson, 2019; Ossipov et al., 2014). Simply put, cognition determinants are nuanced and may run deeper than current practice protocols.
Social work theorists have long acknowledged the importance of social work values in the chronic pain area (Kelley & Clifford, 1997; MacDonald, 2000; Subramanian & Rose, 1988). Social work literature and practice, however, largely deferred chronic pain management to biomedical and psychological sciences and has been caught off-guard by the rapid psychosocial turn. A large survey of health social workers in Sweden found that though workers identified ‘long-lasting’ pain in their assessments, they paid little or no attention to the social contributors, strategies or social supports people have in relation to their pain (Larsson et al., 2019).
Second, pain clinics remain within the normative apparatus of medicine, psychology and education where the literature suggests pain is often ignored and marginal groups stigmatised. Health-care providers, versed in the biological and imaging model of pain, have notoriously underestimated the pain of everyday patients (Prkachin et al., 2007). Further, the subjective nature of pain leaves much to the moral judgement of health workers. First Peoples report experiencing more chronic pain, but are routinely not given specialist care compared to white counterparts (Fenwick, 2006; Latimer et al., 2018). Alcoholics and illicit drug users experience high levels of chronic pain and often feel stigmatised by the health system (Dassieu et al., 2019). Being unemployed or being dissatisfied with work conditions is major determinant of chronic pain (Mills et al., 2019; Vos et al., 2017). Clinicians have been prone to use the concept of ‘malingering’ for these people, but pain experts argue this is a subjective term better left to the legal profession, and should have no place in evidenced medicine (Mendelson & Mendelson, 2004). Similarly people of LGBTQS+ routinely feel stigmatised by mainstream medical services (Crameri et al., 2015). Homeless people often live with trauma and report double the chronic pain of the average demographic and have considerable trouble accessing health services (Landefeld et al., 2017).
Pain British Colombia, an NGO, and the School of Social Work at the University of Victoria in Canada have recently conducted a large study on social marginalisation and chronic pain (Wallace et al., 2021). They used a qualitative community-based participatory research approach to develop knowledge and recommendations based on the experiences of marginalised groups. They formed three focus groups for Indigenous, LGBTQS+, and refugee or newcomer. The research was framed by an Equity Orientated Health Care model called EQUIP which has three dimensions of trauma and violence informed care, culturally safe care, and harm reduction all tailored to the specific context and population (Browne et al., 2018). The participants unanimously expressed “stigmatization, stereotyping, racism, sexism, heterosexism, cisnormativity, and transphobia” by the health care system (Wallace et al., 2021, p.9). The results of the study thus affirmed findings from the literature to date but was primarily used to advocate and test the EQUIP model mentioned above, with many of the authors involved in developing the approach.
I value the resources of the EQUIP programme and believe developing pain clinics based on its principles is laudable. This is primarily an advocacy and funding challenge. Similarly, the rigorous attention to using its three dimensions in research is inspirational. In the meantime, we are still on the back foot with providing inclusive persistent pain treatment. In the Australian context I believe it is likely that we may need to develop a multi-stream model of persistent pain treatment, with different approaches and settings. Developing an education initiative for social workers should be an important recommendation for the national action plan. From a research perspective the first step is testing the hypothesis that public pain clinics do not meet the needs of marginalised groups. In doing so we should conduct interviews with marginalised participants and facilitators of public pain clinics.
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