As a part of our celebrations of Pain Awareness Month in 2019, we are bringing together Doctors, Pain Warriors and Caregivers to share their experiences of dealing with pain. We have been sharing interesting LIVE sessions, Pain Warrior Stories and informational videos daily to commensurate it.
Taking it further today, we have with us Dr. Harbinder Sandhu, who is an Associate Professor and Practitioner Health Psychologist at Warwick Clinical Trials Unit, University of Warwick. She is currently leading a large trial of an intervention that aims to help people with chronic pain taper their opioid use. While she has been actively involved in the field of Chronic Pain for over a decade, she believes there is a lot that can still be done on this.
Join us in a conversation with her, as she shows us the impact of chronic pain on a Pain Warrior and how can one deal with it.
- How long have you been associated with the issue of chronic pain and how?
I have been working in the field of chronic pain for over ten years. I started my clinical role in pain management as a Health Psychologist working in a multidisciplinary team seeing patients one to one as well as in groups. Not long after working clinically within pain management, I started to move my research career into this area too. It made perfect sense to map my clinical and academic work together as working clinically within chronic pain allowed me to see the real day to day issues and reality of peoples struggle with pain, and need for various interventions to help people manage their pain. I could then use this knowledge and information in developing research questions and designing studies to address the needs within chronic pain management.
This can have a devastating impact on an individual psychologically and physically. People can become withdrawn, lose a sense of who they were and the psychological and physical limitations manifest and become the drivers of their day to day lives.
- Being a psychologist, what aspects of chronic illnesses interest you? Any interesting or unique observations over the years? Please share.
As a psychologist and academic I am interested in helping people live better with their chronic pain. Helping them take back control rather than their condition control their lives. I want to help people understand the relationship between the mind and the body and the complex nature of pain. I want to work with people to help them better manage their mood, stress, anxiety, unhelpful thinking, and relationships (whether it be with family, friends, work colleagues or health professionals) and help them gain confidence to be able to manage their pain and rebuild a better quality of life despite long term pain.
My observations over the years are that everyone who I see with a chronic illness has their own unique journey and this is what makes my work varied, challenging and rewarding. However, there are also common similarities, for example many describe having a feeling of a loss of identity to the condition. This can have a devastating impact on an individual psychologically and physically. People can become withdrawn, lose a sense of who they were and the psychological and physical limitations manifest and become the drivers of their day to day lives. I have seen over the past few years a positive trend in research and acceptability amongst healthcare professionals as well as patients in applying the Bio-psycho-social approach to the management of pain. And this is where we can tackle the psychological and physical as well as social impact to help people rebuild their lives.
- You have been part of a large trial of an intervention that aims to help people with chronic pain taper their opioid use. What were the findings? What are the side effects of opioid dependence in chronic pain?
I am currently leading a clinical trial “Improving the wellbeing of Opioid treated chronic pain” the I-WOTCH study, which is funded by the National Institute of Health Research. The protocol paper has recently been published and the aim is to help people who have chronic nonmalignant pain taper off their strong opioids and manage their pain using non-pharmacological techniques. The program we are testing incorporates a cognitive behavioral approach, education, and self-management techniques.
It includes mindfulness and relaxation techniques also. Participants are given group sessions delivered by a lay person (someone who has chronic pain and experience of opioid use and tapering) and a trained I-WOTCH nurse. They are also given one to one support with the nurse for the tailored tapering. Our main outcome measures are activities of daily living (pain interference) and opioid use. We have recruited 608 people to the study from the midlands and North East England and are currently in the follow up stage. Half the participants received the program described above and half received a self-help booklet and relaxation CD care (best usual care). Results will be out late 2020.
Long term use of strong opioids can lead to higher risk of dependence as well as other side effects including severe constipation, drowsiness, decreased memory and concentration, nausea and increase sensitivity to pain. They can suppress the immune system, cause hormonal changes and in older adults there is a higher risk of falls and fractures. For some people being on a small dose of opioids is enough to help them manage their pain, however it is important to weigh up the risks vs benefits.
You cannot separate the mind and body and understanding the complex nature of pain will help understand the impact this can have on someone’s life.
- How much do you think is mental health and chronic pain related and how?
As I mentioned earlier you cannot separate the mind and body and understanding the complex nature of pain will help understand the impact this can have on someone’s life. Often people will have difficulty sleeping perhaps or it may have huge impact on their daily life in terms of work or relationships. Many people may stop doing the things they enjoy, become less physically active which can also have an impact on their mental health.
- How does the invisibility of certain illnesses impact the sufferer? Any observations you would like to share briefly.
Invisibility of an illness can have a huge impact on person’s quality of life. From my observations I often find people become withdrawn, or isolated, they may often hide what they are truly feeling and sometimes put on a brave face in front of family and friends. I often find people feel that communication becomes difficult between family/friends/caregivers and this can lead to misunderstandings.
People can start to lose their identity. With the complex nature of chronic pain and quite often not having a diagnosis or cause for the pain can also add to the burden of living with the invisible condition.
- Do you think Cognitive Behavourial therapy (CBT) can help chronic pain survivors? If yes, how?
CBT is an evidence-based therapy which helps people understand the relationship between their thoughts, feelings and behaviors. In pain management the therapy allows exploration of these in relation to their environment and within context of their physical pain. It allows people:
- To learn
- To become familiar with the way they think
- To adapt skills to challenge unhelpful thinking patterns
- To promote better feelings and positive behaviors
- To understand their role in the management of their pain through managing stress for example, anxiety and the thoughts and emotions behind these.
Often within a cognitive behavioral framework people learn to set goals, manage their fears and learn to problem solve. Often different modalities are incorporated together within pain management, but adapting a bio-psycho social perspective is important. My role as a Health Psychologist is to help people change their behaviors, adapt self-management techniques and help them improve their quality of life despite their pain.
Chronic pain can often be a complex issue to discuss, with uncertainties in diagnosis, multiple visits perhaps to the doctor to help manage the pain. This can become challenging for the doctor and the patient; therefore, it is important we support clinicians and patients in this area through education.
- One of the key areas of your research work has been “doctor-patient communication”. Any important observations that you would like to share?
I have always had an interest in the doctor-patient relationship, it is a key component of healthcare and actually my research career started in this area. Research in doctor-patient communication has grown tremendously over the past decade and continues to improve the relationship and promote better health outcomes as a result. There is a greater understanding of the importance of developing a shared informative approach to decision making, addressing the wider complexities of chronic pain beyond the physical sensation and helping patients and doctors get the most out of their consultations.
For example, writing down questions before seeing the doctor and asking for a summary at the end can help with some of the discussion points. Chronic pain can often be a complex issue to discuss, with uncertainties in diagnosis, multiple visits perhaps to the doctor to help manage the pain. This can become challenging for the doctor and the patient; therefore, it is important we support clinicians and patients in this area through education.
- What do you think are the major differences between chronic pain scenario in India and other countries?
Together with the complex nature of pain, it is important we do acknowledge cultural differences too, whatever these may be. We need more research in cross country comparisons and what we can draw from current evidence of differences and similarities of pain management to address cultural issues. Having an understanding for example of how chronic pain is viewed, the beliefs around cause and treatment as well as stigma associated within a cultural framework can help us better understand the complexities of pain management across different countries.
I believe with initiatives such as Chronic Pain India, this is a great platform and gateway to bring together experts in the field including pain warriors to help further develop this area and help people manage their pain better.
If you are a pain warrior or know someone who is one and would like to share their story with us, please do get in touch with us.