Peer consultants

Chronic pain is a common presentation in general practice. Pain is a global public health priority and can be defined as chronic if it is experienced every day for 3 months in the previous 6 months.¹ In 2007, 3.2 million Australians were affected by chronic pain, with an estimated cost of A$34.3 billion—around A$10 847 per person with chronic pain.² North American data are equally astonishing. Canada has a silent epidemic of people with chronic pain, according to a brief that was presented to parliament on the status of pain in Canada.³

General practitioners are encouraged to use a team approach and a biopsychosocial model for the treatment of chronic pain.^4–6 However, there is still a need for improvement of care coordination⁷ and therapeutic relationships.⁸ The missing link might be a “peer consultant,” who could be part of the community-based multidisciplinary team.

Peer consultants and current evidence

The importance of peer support has been recognized around the world, and Canada even has an established Peer Support Accreditation and Certification standard for the mental health setting.⁹

A peer consultant in the setting of chronic pain could be defined as somebody who has lived with chronic pain, regained quality of life, and expressed a desire to help others. Existing literature suggests that peer consultants find a sense of purpose and make connections in their endeavours to help others, and might have reduced disability and pain scores without any reported harm or increased risk of pain exacerbation incurred from volunteering.¹⁰

A recent review of methods available to treat chronic pain in primary health care recommended further studies into “novel system-level interventions.”¹¹ The study the authors proposed, which would involve peer consultants in the management of chronic pain, can be classified as such. Consulting with a peer could also be classified as a form of “emotional disclosure,” which is a recognized psychosocial intervention for managing chronic pain.¹²

Current evidence suggests that Internet-based self-help for chronic pain has some beneficial effects.¹³ Talking to a peer consultant could be classified as “guided self-help.” Interactive education and freedom of expression can have a favourable effect on participants’ function and knowledge about pain.¹⁴

The belief that others do not understand the level of pain a person is experiencing can have detrimental consequences for an individual’s identity. It can result in loss of relationships (possibly self-initiated) and lead to isolation, guilt, depression, and anger.¹⁵ This goes hand in hand with the results of a placebo analgesia study, in which imaging data suggested a cognitively triggered endogenous modulation of pain when people believe they have received pain medication or treatment.¹⁶ This effect is also demonstrated by the emerging evidence for biofield therapies such as therapeutic touch.¹⁷

Chronic pain and cognition

The relationship between pain and cognition is complex. Pain has a negative effect on concentration and cognitive performance; however, cognitive performance can modulate pain and has substantial therapeutic potential.¹⁸ For example, the role of hypnosis has been discussed in the literature for the past 2 decades, and there is some evidence that it is effective in reducing pain.¹⁹ It is also accepted that fear of pain is a prognostic factor in chronic pain (the fear-avoidance model), which means that addressing the fear of pain can lead to improvement in chronic pain.²⁰ There is potential for using “the narrative affordance of social media” to improve health outcomes.²¹

Narrative medicine and art of free expression

Narrative medicine is “a patient-centred form of medical practice”²² that has created considerable interest in the medical community in recent years,²³ not least since a key article about it appeared in 2001.²⁴ Dr Rita Charon defines narrative medicine as “clinical practice informed by the theory and practice of reading, writing, telling and receiving ... stories.”²⁵ A narrative is as simple as “someone telling something to someone about something”²⁶—the creation of new stories.²⁷

The management of chronic pain requires the assessment and treatment of suffering and pain behaviour; narrative is essential to giving meaning to the patient’s experiences and to assisting in treatment of chronic pain.²⁸

General practitioners routinely use narrative components in daily medical practice: they receive, interpret, co-construct, and bear witness to patient’s stories.²⁹ There is potential for elements of narrative medicine to be used by nonmedical individuals in the same way. This is where the concept of narrative medicine paired with the introduction of a peer consultant could help individuals with chronic pain to help themselves. The hypothesis is that freedom of expression and the creation of a story can reduce levels of distress (and suffering) and improve quality of life, thereby improving patient outcomes.^30–33

There is a need for more research into the role of peer consultants in chronic pain and the benefits to the peers they are consulting with.¹⁰

Arts intervention

Peer consultants could be linked with patients to discover their shared experiences and create a new chapter in their lives through empowerment and the art of narrative medicine. Participants would rediscover their inner voices through expressive writing. The effect of such an intervention could be studied using descriptive and psychometric measures. The Norwegian Pain Society has developed an instrument that examines the outcome domains recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials. It contains components of the Brief Pain Inventory and the 36-Item Short Form Health Survey.³⁴

Conclusion

There is potential for the establishment of a Canada-wide accreditation and training system for peer consultants in chronic pain as an extension of the existing Peer Support Accreditation and Certification (Canada) program.

Further research should focus on the training needs of peer consultants and how they could be integrated into primary health care systems to minimize the gaps in care provision.