Blog 14: The problem with carrots.

Carrots are a well-known symbol for incentives influencing activity. Dangling a carrot in front of the donkey, there was incentive for forward movement in the indicated direction. Sticks were used painfully at the back end of the donkey simultaneously to accelerate the forward movement.

carrot&stick

It is a simple concept to analogise the stick with pain in general, and then consider the predictable behaviour trying to escape its unpleasantness. A nice, big, juicy and healthy carrot would then be pain management based on a broad foundation of pain literacy and a health system that prioritises placing the ‘dangle’ in a SAFE and scientifically effective direction.

Unfortunately, this is not the case in current times.

There are also carrots in front of the person dangling the carrot in front of the person trying to escape pain. In fact there is a whole procession of carrots influencing behaviours all along the way and all these affect the first person trying to escape that stick causing pain in the first place. Going further with this analogy could really mess with the reader’s head so let’s just limit it there. I have written another blog on the ‘zoo in the room’  which is about such perverse incentives in the health system that reward quicker consultations, investigations, interventions, pharmaceuticals and surgeries. These are a general problem but are a distinct ‘catch 22’ problem in pain management. These incentivised methods, consciously or subconsciously, become part of the overall problem. They do not represent direct, reliable and scientifically robust solutions despite abundant ‘beliefs’ and poor science based claims to the contrary. Overall rates of success from the variety of treatments in persistent pain are equivalent to what would be anticipated from weak placebo effects. This is fine for the few who benefit (and would likely have done so in other safer ways) but disastrous for those who don’t. Profitable implementation of new ‘snake oil’ equivalent treatments rampage ahead of solid scientific justification and some obtain public funding just because they become popular. I discovered a recent graphic that makes this dark point again substantially more darkly and fits well with the ‘carrot’ theme –

carrot1

From here on the topic of this particular blog is confined, more simply, to the everyday problems in relation to the first dangling carrot. As elaborated above, pain management prioritises interventions and pharmaceuticals to ‘quick fix’ pain. If trying to desperately move away from the pain stick and offered that carrot how many would choose a different direction? The hoped for ‘quick fix carrot’ wins hands down; there is indeed no contest. Just try to offer a better carrot that is further away and more difficult to reach and you will see that it is highly improbable that the person in pain will take that direction.

It is virtually impossible to manage pain effectively via an educative and re-adaptive neuroplasticity pathway while those suffering it retain the belief that their nirvana lies in a medication, an injection, another intervention or a surgery.

Differentiating between ‘helpful’ and ‘unhelpful’ aspects of care is difficult enough. Having the courage to climb a re-adaptive hill of pain due to perceived harm (not actual harm) to get to the other side is sufficiently daunting anyway. Trying to convince oneself of the need to do these vital things is made seriously more difficult when others offer those ‘quick fix carrots’ one after another after another.

Most who are offered these increasingly hazardous options retain very little understanding of their pain. I am once again drawn to the metaphor of a multilevel house built on a flawed foundation.

The group I am most concerned about in this blog is the group that I am fighting hard to turn around safely and facilitate their best best neurobiological (and structural) re-adaptive recovery. Despite ardent efforts and much time spent, patients regularly focus on any offered surgeries, medications and other offered interventions and therefore the crucial ‘buy-in’ factor in the brain is very difficult to achieve.

The relentless thinking that something needs to be fixed for pain to be relieved is one of the strongest factors perpetuating that pain (there is that ‘catch 22 effect again). This a powerful feed into the ‘danger’ side of the brain’s pain equation eg:-

“I need my disc to be removed / my spine fused or my pain won’t ever go away”.

“They are telling me to do exercises but my disc is torn and bulging and I could make it worse; surely it is best fixed first!”

“They tell me my (insert any) joint is degenerate / arthritic. There is no way it will just get better and stop hurting without an injection / clean up / replacement!”

When this thinking is fuelled by an abundance of expert practitioners endorsing flawed ‘fixing’ processes, the situation is rendered almost beyond help. I wish I had kept count of how many times I have encountered the neuroplastically disastrous comment – “one day I believe that you will need a joint replacement”, or many similar such statements.

The carrot I offer is based on science and not ‘belief’. It advises that the only relationship between pain and discovered ‘degenerate’ changes in regions of pain is via electrical signalling to a pain response. It confirms that this signalling is not actually even necessary for that pain response. Furthermore the signalling part becomes less likely to be involved as a significant factor with the passage of time. It educates that the context of a pain event is significantly more influential than the electrical signalling and becomes more so with time. It advises about powerful placebo and nocebo psychobiological responses and that as a result what is told to patients and what they subsequently believe determines their outcome much more significantly than their structural body changes. It honestly informs that pain has become a greater problem despite major scanning and ‘fixing’ technology advances and explains the ‘inconvenient truth’ that these financially lucrative carrots are actually part of the problem rather than the solution. Etc …

And that last bit is the main thrust of this blog. From a practical real world perspective, in order to convince patients in pain that the carrot I offer is the juiciest and most rewarding, what is needed is to get them to stop drooling over the other carrots. A vitally important component of ‘pain literacy’ is to provide an honest appraisal of the real outcomes and poor science base for pretty much all other treatments and the potential dangers, not true benefits, of following those directions.

You can probably guess how popular that makes me with some of my colleagues.

I look forward to the day when the procession of motivating carrots is whittled down to the best ones by a self reflecting health community more interested in truly meaningful outcomes than worshiping engrained beliefs, flawed processes and ‘stakeholder’ interests. However, the sad likelihood is that this will likely only occur when those who finance our health, create incentives for such meaningful outcomes rather than financially reward existing processes just because they are popular. It will be a shame if it takes reaching the inevitable financial crisis point to convince the need for such change rather than simply recognising the current, prominent human crisis alone. That too reflects the ‘problem with carrots’.