Pain in Singapore

Nearly one in ten Singaporeans suffer from chronic pain. What causes chronic pain, how do people treat them, and why has it been support for the condition been scarce?

July 10th, 2014 was a normal day. The World Cup was drawing to a close; and like much of the world, Ivy Li had been following the championship and the shock 7-1 win Germany had over Brazil in the semi-final two days earlier.

At home, she was preparing to head out to her volunteer job at a local animal shelter.

Then, the former gymnast fell — “gracefully,” as she puts it — on an IKEA clothes rack.

Even though the bruise she got from the fall was “gigantic”, the 30-year-old thought nothing of it. She, like her mother before her, had low blood pressure, which left her prone to bruises.

But the intermittent back pain she’d had for years before the fall — caused by carrying big dogs for her rescue work and training for gymnastic routines — never really went away.

Back then, Li — who now suffers from chronic lower back pain from a slipped disc — never thought of going to the hospital. It never occurred to her that something serious could have happened.

She went to see a traditional Chinese sinseh, who doubled as a chiropractor, and was told that her back wasn’t aligned.

After, she went to a separate acupuncture session with an acupuncturist to try to get rid of the pain.

“This time it was different,” she says. “I was in tremendous pain. I told the practitioner to please remove the needles. And then she suggested that this could be something more serious, and that I would have to go for a scan.

“After the session with her, that very night, I could not lift my arms,” she adds. “It was so painful — my whole body was paralysed with pain.”

Li’s ordeal is similar to thousands of Singaporeans who suffer from chronic pain. Hospitals now see more chronic pain patients a year; nearly 8,000 have gone to pain specialists at Singapore General Hospital (SGH) in 2017, compared to 6,000 in 2015, while at the National University Hospital, doctors saw about 2,500 chronic pain patients last year, a 10 percent increase from the year before.

Yet, knowledge regarding chronic pain and its impact on the city has been scarce, and estimates on the number of people with chronic pain vary.

A 2009 study estimated that 8.7 percent of Singaporeans suffered from chronic pain, while a more recent 2016 study put the number at about 14 percent; global estimates suggest that as many as 20 percent of adults suffer from it.

Chronic pain — defined as pain that has persisted for more than three months, affecting sufferers’ daily activities — is difficult to diagnose and treat.

An estimated 70 percent of chronic pain patients seen at SGH suffer from pain in the musculoskeletal system, caused by injuries or wear and tear to bones, joints and muscles — while another 20 percent suffer from neuropathic pain, caused by disorders in the nervous system.

Pain sends a blow to both productivity and quality of life in general, according to Sharon Mak, director of communications for GSK Consumer Healthcare in Southeast Asia.

A 2017 study by pharmaceutical company GSK estimated that nearly half of Singaporeans suffer weekly from body pain. Workers in Singapore took an average of three sick days due to body pain last year, according to GSK’s study — and this, on top of reduced workplace productivity, is estimated to cost the country 2 percent of its gross domestic product — or over $8 billion — annually.

Still, despite its disruptiveness, over half of Singaporean respondents have kept quiet about their pain. “We do go to work, but the reduced productivity at work due to health problems is even higher,” Mak says.

Singapore’s support of chronic pain sufferers, however, has been scarce.

Dr James Tan, who is a council member of the Pain Association of Singapore, a group of professional pain doctors, says that the group has asked the Ministry of Health to recognise pain specialists twice in the past, but the Ministry did not respond.

“I think the Ministry feels that this is not a pressing need, that maybe the number of people involved in treating chronic pain is still low,” Dr Tan, who is also director of NUH's pain management service, says.

While spending to prevent non-communicable diseases and chronic conditions has been a sign that the government is taking healthcare seriously, it’s normal for governments to focus on conditions that might impact a wider population, Mak says.

“The government does look at all the health conditions, and they are taking a lot of active steps to encourage people to be responsible for their health,” she adds. “Pain, because you don’t really see that, it’s not a critical factor that has an impact on productivity.”

Factors causing pain

Medical science has increasingly recognised the collective impact of psychological, social and economic factors in patient recovery. Scientists say that the subjective experience of chronic pain occurs as part of a complex interaction of biology, psychology and social actors in what they call the biopsychosocial model.

That means that other than assessing the cause of the pain, they also need to look at how sufferers experience pain and its social, emotional and economic effects.

“In chronic pain, we recognise that if someone has back pain, they will actually move less,” says NUH’s Dr Tan. Most avoid activity that may trigger pain, a concept widely known as fear avoidance.

Chronic pain is essentially a dysfunction of the body’s central nervous system, Dr Tan says. Many things can happen when the human body is exposed to pain daily.

“These changes can result in long-lasting pain when there is actually nothing wrong,” he says.

“A simple way to think about it is that you have an amplifier system in your body for pain, and in chronic pain patients, someone has turned up the amplifier, so that even little stimulation or non-painful stimulation becomes painful.”

As a result, sufferers who move less will become weaker, and also lose contact with friends — which in turn, drives them to think about their pain. They end up being unhappy because they think that their friends and family don’t understand them, says Dr Tan.

“If you just focus on treating the biological part, then the patients may not get well,” he adds.

But apart from biology, other factors tend to be overlooked. A study of 15 local health professionals including pain doctors, pain nurses and physiotherapists among others, found that health workers often had preconceived ideas about how patients viewed their own pain, and that older schools of thought still prevailed.

“Generally, people misunderstand chronic pain,” says Dr Yang Su-yin, who was lead author of the study published in the journal Disability and Rehabilitation. “Even health professionals, those who don’t have a full understanding of the psychology of pain, would then think that it’s psychosomatic pain, because there is no (clear) pain generator.”

Treating pain

There are two types of treatments for chronic pain — conservative and invasive. Conservative treatments include non-pharmacological therapies like physiotherapy, acupuncture, chiropractic treatments and meditation, as well as pharmacological treatments like opioids and NSAIDs; invasive treatments are usually interventional, like joint and spinal injections.

Doctors usually take a multi-modal approach to try to manage or change patients’ pain, says Dr Tan Kian Hian, senior consultant at SGH’s pain management centre. Each treatment has its own risks and benefits, and while doctors aim to reduce suffering, treatment effectiveness also hinges upon how much relief a patient expects.

“It depends on the medical condition of the patient, coupled with the type of pain, and the appropriate medications which may benefit the patient,” he adds.

Doctors and healthcare professionals say they have to manage patients’ expectations about treatment.

“In the patients’ perspective, they want to return to a normal life,” says Christopher Lo, a physiotherapy lecturer at Singapore Institute of Technology (SIT). “First we need to make sure that the patient has proper expectations — it may not be likely for the patient to live a pain-free life.”

There may not even be an “absolute relationship” between damage and pain, he says.

In some cases, Lo says, even when a sufferer is in pain, their joints and muscles may still be functioning normally. “Some people manage to control the pain to a bearable level so that they can maintain the function,” he adds.

As a result, specialists of body and mind work together, and psychologists also manage patients’ beliefs about treatment.

They agree that the first thing the patient wants is to get rid of the pain as soon as possible.

But what that does is reinforce the idea in the patient’s mind that a physical intervention will fix it.

“With any of us, with pain, we believe it to be a sign of damage, so we want to get rid of it and avoid it,” says Dr Yang, clinical lead for pain psychology at Tan Tock Seng Hospital (TTSH). “So the expectation is that any treatment that I seek should help me to get rid and avoid the pain.”

Dr Yang conducts cognitive-behavioural therapy, where patients are equipped with coping skills to change how they think and react to chronic pain. Methods like guided imagery, desensitisation, and acceptance and commitment therapy are used to support patients in managing their own pain.

But painkillers — like non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol and opioids have always been at the core of pain management and relief.

Guidelines by the Pain Association of Singapore help doctors determine if the drug they prescribe is right for the patient, says Dr James Tan of NUH.

“The idea then was the (Pain Association) felt that there was an increasing problem of some patients who were asking for opioids, or who were not being well-managed when they were on opioids,” he adds.

Pain specialists agree that, in the long run, opioids are not for every patient. “A lot of patients just get tolerant, that means the drug loses its effectiveness.”

The biggest group who benefited from opioids at NUH have been the elderly, who may not be suited to invasive surgery because of their age, Dr Tan says. “In this group of patients, the risk of addiction is low, and if you know how to use the drug carefully, you can actually help to relieve pain without causing any serious side effects.”

Patients at NUH sign a contract stipulating that they can only take opioids as prescribed, and that they can only collect opioids from the hospital’s pharmacy.

“(The contract) states clearly when the opioids may be stopped by the treating physician if we find that it is not helping them, or if they are getting addicted,” Dr Tan adds.

Sufferers often have misconceptions about opioids as a method of pain relief, he continues.

“A lot of times they are reluctant to start,” he says.

Lim Hwei Ming was prescribed tramadol, listed as an opioid under Pain Association guidelines.

The 38-year-old business development manager, who suffers from back pain from a slipped disc, and says that if the pain was still at a level which she could manage, she wouldn’t take her medicine.

“Let’s say I take it, maybe I would have to depend on it, and if I couldn’t get rid of the pain in time, then perhaps I cannot manage my work or my lifestyle well,” Lim adds.

Similarly, Shawn Danker, a 39-year-old freelance photographer, says he has to take opioids like tramadol because he is allergic to NSAIDs.

“I discipline myself, so I only take it when I need it,” he says. “Sometimes if I can tahan I just tahan.”

Dr Wong Li Lian, a senior lecturer at the Department of Pharmacy at the National University of Singapore, says that people should understand that they need to take the right dose of medication for the right duration for medicine to be safe to take, and that there are alternatives to opioids that can help sufferers manage pain. For many, paracetamol would suffice.

“A lot of people think that paracetamol is not a good pain medication, but that’s not really the case,” she says.

“If the pain is relatively well-controlled, they could always change it to something else that could also help them manage the pain and has less potential for addiction.”

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