If the meaning of the phrase ‘catch 22’ is googled one of the first definitions discovered is:
“a dilemma or difficult circumstance from which there is no escape because of mutually conflicting or dependent conditions.”
For any potential younger readers who do not recognise this term or its origins, I direct you to the original book of the same title by Joseph Heller in 1961 that was made into a well known movie (well it was well known in my generation):
The phrase described absurd bureaucratic constraints on soldiers in the second world war. The term was introduced by the character Doc Daneeka, an army psychiatrist who invoked “Catch 22” to explain why any pilot requesting mental evaluation for insanity (hoping to be found not sane enough to fly and thereby escape dangerous missions) demonstrates his own sanity in making the request and thus cannot be declared insane. This phrase then filtered into common usage for similar situations as per the googled definition above.
In my regular day to day dealings with contemporary management of pain in an orthopaedic setting, I all too frequently find myself thinking of this phrase. I have therefore decided to present many of these moments here to make the point that when managing pain we need to realise that we can’t have things both ways. We need to recognise the likelihood that the very things we do regularly in our current model of care are quite capable of producing pain resistance and amplification in vulnerable people. Many are similar in message but differ in the origin or context that is applied to the patient in pain.
Rather than do the usual thing counting down from the least to the most worthy, I will do the opposite in consideration of possible limited attention spans. If you seek the usual suspense in your reading, you can just read the blog backwards.
1. Informing a patient that a structural change discovered on an investigation is seriously contributing to or causing their pain. This is a very common method employed by so many in the current management model. It is becoming increasingly recognised as a problem. It ranks right up there in sophisticated thinking with looking at a straight horizon line and deciding that the earth is flat. The association between developmental and degenerative structural changes (the majority of what is found) and levels of pain is NOT linear; not even close. Given that ultimately pain is generated when the brain’s perception of ‘danger’ is greater than its perception of ‘safety’ this is a very problematic method feeding much more into the danger side of the equation. The outcome is then determined by the patient’s psychological and sociological affiliation. So, if they are in that group who ignore bad advice they will be OK. But if they believe your expert opinion, and contextual influences are not good … there is serious potential for trouble and actual harms. And all from such an innocent and common ‘nocebo’-inducing statement. I have many excellent examples of how often this is a problem. Unfortunately, many well regarded surgeons who see things in so wonderfully a linear way (pain + scan change = diagnosis for intervention) do it very commonly with no concept of the double-edged sword (scalpel?) that they wield with their words. Another particular worrying example I recall is a case of a pain management physician reporting on and on about discs and facet joints etc, etc because of the scan, while others in his own multidisciplinary pain management team were simultaneously documenting discordant pain, context problems, poor pain literacy, catastrophisation etc. And then guess what happened? (not difficult). This poor fellow listened to the pain physician primarily and then to the surgeon to whom he was referred and became convinced that his spine needed ‘fixing’ for pain relief. His pain persisted and was resistant to all rehabilitation initially and then to all scan focussed treatment, including a misguided spinal fusion. It was also resistant to approximately 120mg morphine equivalent per day. As stated, I have MANY similar examples of people following the wrong ‘fork in their pain road’ because of such basic ‘catch 22’ expert advice.
2. Managing pain as a therapist or a medicolegal examiner without having a proper neuroscientific understanding of pain. I think the catch 22 here is quite obvious. It is a little scary to consider that patients come in with the same problem ie: ‘pain’. Their management is then completely dependent on who they see offering their particular perspective as a priority. Imagine if we approached airplane maintenance in such a fashion. It is therefore disturbingly fascinating to me that I am having regular conversations with so many who have extraordinarily little understanding of pain beyond structural factors. Basic pain terminology is often poorly understood and if understood is poorly prioritised. And most worryingly, this abundantly includes those with ‘pain management’ credentials. I vote we discard such titles as ‘interventional pain management’, ‘pharmaceutical pain management’, multidisciplinary pain management etc and just manage pain in a consistent manner with the foundation being the simple priority of excellent pain literacy. We can’t expect this in our patients if we don’t achieve it in ourselves. Neuroplasticity processes can only be expected to behave positively if this is the foundation. This safe, low expense, educative measure should be a vital prerequisite prior to interventions, pharmacies and surgeries; not afterwards, when the horse has bolted.
3. Offering the comment – “there are no other factors involved in this person’s pain” as an expert opinion. This follows on from the previous ‘catch 22’ (which is a slight problem if you are reading this backwards for the ‘suspense’ effect). Please can we collectively agree to ban these types of comments referring to anyone in pain. I read this utterly illogical comment in the majority of independent medical and other reports that I read. Not in the minority; quite definitely the majority. It is often even more ridiculously frank – “there are no psychosocial factors affecting this person’s pain”. And the really scary thing is how much these comments affect the lives of the poor people to whom they refer via influence on treating doctors, therapists, case management and legal considerations. It is imperative for professionals to have a basic understanding of pain to see how unsound these types of comments are. Every person, especially in our increasingly highly strung and decreasingly resilient Western society, has psychosocial stresses in their lives capable of affecting the ‘danger’ side of their pain equation. To consider that discordant pain responses are only possible in patients with highly overt psychological disorders is narrow and discounting of the realities of life. It also ignores the highly emergent nature of pain and wrongly informs the patient that their pain is solely due to structural flaws even though these are present abundantly in people with no pain’. Medical examiners in particular have an obligation to have a high pain literacy level themselves. The principle of ‘first, do no harm’ applies because of the significant influence they have on patients’ pathways.
4. Labelling someone as having ‘non-organic’ pain, or similar, just because their scans happen to be normal. Once again, it all comes down to pain literacy. If a patient is suffering contextually influenced pain and is told that they have ‘no right’ to be in pain because their structure is not visually serious enough, consider how that affects the pain ‘equation’. I have reviewed many cases such as these and observed the extreme confusion, perceived need for justification, desperation and dismal outcomes of such patients.
NB: Less explanatory detail will be provided for the remaining points. Please consider them all in terms of the pain ‘equation’ and similar factors as discussed above.
5. Telling patients in pain that their only real option is to ‘learn to live with their current level of pain’ when that result is undeserved given the clinical situation. The message ought to be that the pain can be diminished to ‘normal’ protective levels via neuroplasticity processes and good rehabilitation once the pain literacy level improves. Stating it in the manner described actually makes it more likely that the pain will persist or, as is commonly observed, that comment also results in a percentage of desperate patients seeking more harmful ‘cures’ as they find the prospect of ‘living with their pain’ unacceptable.
6. Failing to understand that there is MORE potential for nociceptive and neuropathic input to pain AFTER most surgeries for pain, due to complications, scarring, altered anatomy, adjacent stresses etc. Just consider Biology 101 and take a look at many ‘before and after’ comparative scans if you don’t believe me.
7. Considering that educative pain management is only appropriate AFTER surgery directed at non-specific changes. This has actually been stated to me repeatedly.
8. Ordering investigation after investigation when pain persists. Consider what message this is giving the patient in pain and how that reflects a lack of pain literacy on the part of the clinician.
9. Ordering investigation after investigation when pain persists and then amplifying any inevitably found minor investigation change/s in significance and advising this to the patient in pain. The only reason this doesn’t rate higher is because the patient is a likely pain ‘basket case’ by now.
10. Considering that inaccurate diagnostic injection responses are good justification for structurally targeted interventions and advising patients in persistent pain – “I believe this is the source of your pain”. This is also representative of the many structurally obsessed “banging a square peg into a round hole” things that are done and supported as the ‘art’ of medicine.
11. Marketing pain management services eg: an obtained award for ‘excellence in pain management’, when that is only provided from an unbalanced intervention perspective. Interventional pain management can in itself be a ‘catch 22’ as it is highly prioritised on targeting scan discovered changes or on the basis of clinical ‘gumption’.
12. Failing to consider placebo construct responses to structurally focussed management and then advising patients how effective the management is based on anecdotal or dubiously audited outcomes.
13. Touting the next (and the next and the next) ‘miracle cure’ for persistent pain. Convincing patients in pain that they need a ‘cure’ keeps them looking in the wrong direction and dis-empowers them. This is almost always done without consideration of the need for first obtaining soundly constructed sham controlled trials. It would also help if the poor results were believed and suitable change implemented when seen, rather than just ignoring the evidence because it doesn’t suit or fit with the professional’s ‘expert clinical experience’.
14. Having financial incentives that strongly encourage shorter consultations, imaging and procedures.
15. Applying higher doses and combinations of various medications including morphine based medication and failing to recognise that the pain is actually resistant. “Here, have some more.”
16. Repeatedly relying on potent analgesia for pain management in discordant pain, and then spending the next phases of management ‘mopping up the mess’ ie: trying to cease the medication because of the almost inevitable drug dependence or similar problems.
17. Blunting patients’ cognitive processes with potent analgesia and other medications while simultaneously trying to educate them to make informed decisions on their management options.
18. Telling patients that their psychological problems are ‘secondary’ to their pain. ie: “when your pain is ‘cured’ by others, your psychological / psychosocial problems will reliably improve”. This is a common ‘catch 22’ that probably should have rated higher but was incompletely covered earlier (number 3).
19. Constructing pain management programs that prioritise structural changes, even as actual ‘red flags’, and even though these are seen commonly in people with no symptoms . Maybe this is why patients who have been through one or more pain management programs regularly still perform poorly on my pain literacy test.
20. Accepting as eg: a surgeon that compensation patients have post-surgical outcomes that are significantly poorer than non-compensation patients, yet stating stridently – “do you expect me to treat my patients differently? Well … yes, I do.
21. Creating a health system which results in the following statements being made to me directly:
a) Physiotherapist: “I used to practice biopsychosocial, educative pain management but I stopped because I received no support from the GPs and specialists around me.
b) Surgeon: “I spend most of my time educating patients that they don’t need surgery but then they go off, get referred to another surgeon who operates on them and I never see a referral from that GP again.”
22. Bureaucratic insistence that the ‘system’ is a success overall because approx 70% ‘do well’. This ‘pat-on-the-back’ message seems to be just ‘marketing’ the meaningless positive message for political benefit like in the UTOPIA series on ABC TV recently. I would confidently state that 70% of people will do well in ANY system via natural human survival instincts, sociological subgroups and placebo responses.Tragically, about 20-30% are faring very poorly and this epidemic-equivalent number is still increasing. Furthermore, to my knowledge, this 20-30% group generates 70-80% of the relevant health related area incurred expenses!
Initially I thought I would have difficulty populating the 22 for this blog title, but having completed the blog I can actually think of a few more!
Look at this media poster warning transport workers of the fragility of their spines and consider the pain ‘catch 22’ effect:
In order to meaningfully improve the statistics of persistent pain in Western models of care we must start to acknowledge the overloaded seesaw of the brain’s pain equation due to the preponderance of ‘danger’ >>> ‘safety’ oriented information. That is the reason ‘context’ is so much more important in determining outcomes than ‘pathology’.
PS (27/02/16): A number of my patients reminded me of another pain catch 22 recently. This is what I refer to as the ‘entitlement addiction syndrome’. This happens commonly due to the largely subconscious thought that many have that they require continued access to funding of treatment expenses for their biologically long healed / re-adapted injury ‘just in case’. By simply perceiving the need for access to funds that are far more generous than can be obtained normally, and possibly even compensation for perceived injustice, pain can persist via neuroscientific processes. This is NOT malingering or other derogatory terms such as ‘secondary gain’ in many (most in my experience); it is just how the brain works trying to protect us. Lawyers and legislators take heed – you may be part of the problem, not the solution. If I offered you money or health and happiness but you couldn’t have both, which would you choose?