Commentary: Chronic pain is a billion-dollar headache for Singapore
As Singapore's population continues to age, chronic pain could place a strain on the country's healthcare system. Pain specialist Dr Bernard Lee looks at how Singapore can bridge gaps in this area.
As Singapore's population continues to age, chronic pain could place a strain on the nation's healthcare system, support services, and caregivers. (Photo: iStock/SARINYAPINNGAM)
SINGAPORE: Imagine waking up every morning to a stabbing pain on the side of your head, with every movement or sound making the pain more intense. Imagine having such agonising back pain that you are unable to stand or sit for more than an hour.
In a survey done in 2009, 8.7 per cent of respondents in Singapore reported living with chronic pain, defined as pain that persists for at least three months. The prevalence was higher among individuals living in a low socioeconomic-status rental-flat community at 14.2 per cent.
Similar numbers have been reported from studies of Singapore adults with chronic lower back pain (8.1 per cent), and migraines (8.2 per cent).
As Singapore's population continues to age - with one in four Singaporeans expected to be 65 and above by 2030 - chronic pain could place a strain on the nation’s healthcare system, support services and caregivers.
The management of chronic pain in Singapore is a potential area for transformation, as the government prepares to launch the Healthier SG initiative to tackle the challenges of an ageing population and the rising impact of chronic disease through the mobilisation of general practitioners (GPs).
IT’S NOT ALL IN MY HEAD
Pain is a multidimensional, complex, and unpleasant sensory and emotional experience. When you stub your toe, for example, the sensory receptors in your skin send a message through your nerve fibres and spinal cord to your brain where the sensation of pain is registered, information is processed, and the pain is perceived.
Chronic pain can be considered a disease because it is accompanied by biological changes that involve cellular and biochemical processes. 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.
Sometimes, individuals can experience pain without a physical or structural cause, which may be associated with psychological trauma, making it even more challenging to diagnose and treat.
But the persistent nature of chronic pain disrupts the lives of those affected, limiting their mobility, impeding their daily activities, and eroding their quality of life. It can also have economic implications.
A 2019 study involving about 600 Singapore-based employees with migraines showed that 81 per cent had between one and three headache days a month, while the remaining 19 per cent had four to 14 such days a month.
The total cost to Singapore for episodic migraine in 2018 was about S$1 billion (US$745 million), mainly due to missed workdays and lost productivity.
Generally, the sooner the cause of pain is identified and treated, the less complex and less expensive it is to manage the condition.
EMERGING THERAPIES TO TREAT CHRONIC PAIN
Not many people know there is a variety of minimally-invasive procedures that have been proven to be effective in treating chronic pain.
Treatments using radiofrequency, radiofrequency ablation or platelet rich plasma therapy, for example, breaks down scar tissue, inhibits the nerves from transmitting pain signals, and encourages healing at the site of the pain respectively. Emerging therapies such as nucleoplasty, neuroplasty or epidurolysis are used to treat pain in the legs and back.
Meanwhile, cognitive behavioural therapy utilises breathing exercises, stretching, and positive association with pain to help reduce the patient’s reliance on medications and return to daily activities and work.
STEPPING UP SINGAPORE’S PAIN MANAGEMENT APPROACH
Conventionally, patients with chronic pain are prescribed opioids such as morphine, codeine, and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. However, painkillers do not address the underlying cause of chronic pain, and their prolonged use can cause more harm than good.
Prolonged use of NSAIDs has been linked to gastrointestinal ulcers and bleeding, while the use of opioids can create dependency in the long run.
Instead of relying on painkillers, a multidisciplinary approach is fast becoming the standard of care in chronic pain management in countries such as Australia.
In those countries, chronic pain is approached and treated as a condition in and of itself, instead of a symptom of a disease. GPs are the first line of the triage, leading the treatment and working closely with allied health professionals.
They may consider minimally-invasive procedures, patient education, behavioural therapy, cognitive therapy, physical therapy, family therapy, surgery, and more.
This is unlike in Singapore, where GPs tend to refer patients to a specialist if they are unable to treat the condition, depending on where the pain is situated. For example, the patient is likely to be referred to an orthopaedic surgeon if the pain is located in the knee, or a neurologist if he is experiencing frequent and intense headaches.
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Encouragingly, some hospitals in Singapore have recognised 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 health system’s patient monitoring structure.
If Singapore aspires to bridge gaps in pain management, it is important that more Singaporean doctors and GPs are trained in this area.
The more GPs who are trained in pain management, the more options patients would have to manage their condition, and the higher likelihood they would be treated with minimally-invasive therapies and recover more quickly with less downtime.
The view of pain specialists is that pain can be removed, and pain generators eliminated, without necessarily subjecting the patient to an invasive surgical procedure.
They view pain management with a customised, patient-centric lens, instead of a “one size fits all” solution. No matter what treatments are prescribed, the ultimate goal is that patients are able to lead pain-free lives.
Dr Bernard Lee is Senior Consultant Pain Specialist and CEO at Singapore Paincare Holdings Limited, a medical service group focusing on chronic pain management.
