Summary of International Best Practice Evidence

The literature reflects the need for more effective management of pain, particularly for those who experience chronic pain. This necessitates a model of care which is inclusive of, yet far broader than, the traditional, biomedical approach which focuses on ‘curing’ pain. There are many examples of comprehensive approaches to chronic pain management internationally.

The emergent models have the following consistent themes: • Recognise the interaction of biological, psychological and social factors in the experience of and response to pain and aim to provide a suite of interventions and therapies to address these. • The need to adequately resource and tailor a pain service to suit the needs of young adults to run alongside paediatric and adult services. • The importance of child and whānau centred sociopsychobiomedical care and the benefit of intensive interdisciplinary pain treatment delivered in an outpatient or inpatient setting when indicated. • Align to principles of health promotion, prevention, and early assessment and intervention. • Are directed toward developing greater self-management of chronic pain. • Require a strong primary care network. • Are interdisciplinary and operate across the interfaces of primary, community and acute health. • Provide specialised pain services across inpatient, outpatient and outreach settings. • Are oriented towards outcomes for both patients and the health system as a whole. • Are informed by the best available evidence.

Adults with chronic pain

The literature consistently shows the benefits of a sociopsychobiomedical approach to chronic pain management. The transdisciplinary team may include but is not restricted to a pain medicine specialist, nurse, physiotherapist, occupational therapist, pharmacist, and psychologist. Assessment for inclusion in a pain management programme should include appropriate screening to exclude underlying treatable disease, to discuss treatment options or the lack of them, and to introduce the concepts of persistent pain and pain management through education.

A group educational program prior to entry into the pain service has shown benefits for some patient groups. Pre-assessment education can be used to enable those referred to

a chronic pain service to gain an accurate appreciation of the service and the opportunity to decide if it could meet their needs.

Screening can be used to identify the factors which are likely to present as obstacles to recovery. It can stratify patients by psychosocial risk and can guide treatment decisionmaking in a clinical setting as well as clarifying patient expectations of outcomes and goals for the programme prior to it commencing. Admission to chronic pain management programme should follow appropriate transdisciplinary assessment to confirm suitability and identify relevant individual goals. Treatment may be delivered face-to-face or remotely or through a combined approach. There are benefits to telehealth services for some patient groups.

The following were identified as non-pharmacological areas that can be improved through transdisciplinary sociopsychobiomedical care (Alberta Pain Strategy, 2019): • Pain assessments • Shared decision-making tools, • Consideration of all aspects of an individual’s pain experience • A need to screen patients to determine who is at risk of transitioning to chronic pain

Person centred care pathways with transdisciplinary specialist pain capacity can: • Improve early access to pain assessment, treatment, and management • Enable models that work across regions to support seamless care and consistent access to specialty hubs • Ensure equity in access and pain care to Māori, Pacific peoples, and rural-remote communities

Māori experience of chronic pain

Research and the 2020/21 NZ Health Survey has shown that Māori adults are 1.4 times more likely than non-Māori adults to self-report chronic pain (Gatchel et al, 2014). Māori are less likely to visit their general practitioner for pain management and experience barriers accessing specialist pain services in Aotearoa New Zealand (Taylor et al, 2004). Research from 2018 found Māori who attended a chronic pain service presented with a significantly higher need for healthcare when measuring clinical outcome measures. As well as having higher pain, Māori presented with greater disability, higher levels of depression, anxiety, and stress, lower self-efficacy to manage pain, higher levels of painrelated fear and more catastrophic thoughts related to pain (Burri et al, 2018).

Previous experiences of racism in the healthcare setting and a lack of culturally responsive services, as well as support and access barriers for pain services likely contribute to the inequities in access and outcomes (Harris et al, 2006). The four main themes that emerged from research on Kaiāwhina Māori health workers’ perspectives on pain management for Māori were: • that treatment of chronic pain in primary health relied exclusively on medication • health literacy approaches to pain management are urgently required • Māori have significant unmet need for culturally responsive pain management • the availability of, and referral practices to, specialist pain management services are limited for Māori communities (Devan et al, 2021).

Both Māori and Pasifika cultures have a holistic view of health with a larger emphasis on family and spiritual aspects than traditional Western models. There is little research on how these different cultural lenses may influence the impact and management of chronic pain in these populations.

Research supports the need for culturally appropriate pain management resources, services, and support to be adopted to address the current inequities in prevalence of chronic pain and access to pain services (McCavock, 2011). Literature supports further research and implementation of Māori models of health and wellbeing such as Sir Mason Durie’s Te Whare Tapa Whā model which describes a holistic view of health and wellbeing that reaches wider than the western biopsychosocial model. Research supports the need for a co-designed mātauranga Māori service for chronic pain management that reflects Māori models of health and wellbeing and are culturally appropriate.

Understanding the lived experiences of pain among Māori is an important aspect to consider and to address in models of care to provide effective care (Pitama et al., 2011; Shipton, 2013).

Paediatric chronic pain

The evolving standard of care for paediatric chronic pain involves a transdisciplinary treatment team that delivers child and whānau centred sociopsychobiomedical care. The child’s care should focus on, and be organized around, the health needs, preferences and expectations of the child, and their families and communities.

The child and their whānau should be treated in a comprehensive and integrated manner with all aspects of the child’s development and well-being attended to, including their cognitive, emotional, and physical health. The child’s educational, cultural, and social needs and goals must be addressed as part of the care management plan and treatment. Such programmes are developed to maximise age appropriate activities and are mindful of developmental and different social and emotional and cultural needs of the child and their whānau. Whānau involvement and education are core to successful paediatric pain management programmes. Programmes are developed to promote engagement and support children and their whānau to have an active role in care through communication and shared decision-making around pain management plans and progress.

Adolescents with chronic pain

Adolescent services are unique in that some cases involve a transition of a young person from paediatric to adult services while in other cases this is the young person’s first experience of chronic pain and treatment. The adolescent group generally ranges from 14 to 25 years. These chronic pain services have a focus on increasing independence and self-management in treatment and in managing access to services and appointments.

In some situations, adolescents are treated within a paediatric programme, while in others, adolescents are included within the adult programme or, within a specialised adolescent service that is separate from both the paediatric and adult services. Maintaining engagement and support for adolescents/young adults is important

particularly given this can be a point of drop-out from the service as independence is encouraged and parental involvement in treatment may decrease.

While paediatric services are whānau centred, adult services are more independently orientated. This be a challenging transition especially given the increased reliance on parental support that is seen in young people coming through the paediatric pathway. There is a focus on developing capacity to understand and appreciate the treatment options, explanations, and consequences and fully informed consent, developing the tools and skills needed to manage persistent pain independently.