Patients referred from a multidisciplinary pain clinic to the social worker, their general health, pain condition, treatment and outcome

1 Introduction

Social workers have an essential role in the therapy of pain patients at multidisciplinary pain clinics [1]. The objective of social work in this setting is to remove or alleviate any social factors that may adversely affect the treatment of pain patients [2,3].

The working methods used in practical social work support pain management through various therapeutic approaches ranging from social welfare and financial counseling to supportive discussion and even psychotherapy [4]. On the other hand, some conditions may require that the whole treatment team shares a common therapeutic strategy to relieve the patient’s condition. The use of therapeutic strategies is typical of social work involved in the treatment of mental disorders [5,6] in which the interaction between the patient and the therapeutic staff is paramount. Mental disorders occur in patients with chronic pain to a significant extent [7,8,9]. This, too, supports the use of varying therapeutic strategies at pain clinics. Since social workers are a part of the care provided by a clinic [3,4] they should also work within the treatment strategy drawn up by the clinic. Consequently, this requires of the social worker an understanding of the client’s conditions. We believe that the range of issues that social worker’s clients present has not been researched.

In the absence of systematic research, the mental and physical health of patients visiting the social worker’s office in pain clinics is unknown. This information would, however, benefit the social worker in determining which health problems to look for in patients with chronic pain. The information on where the patients come from and where they go from the pain clinic is also relevant in ensuring that the recommendations made by the social worker are followed. The aim of this study was to provide information about patient’s putative health problems for the social workers working with chronic pain patients in pain clinics.

2 Methods

The present study was a retrospective descriptive investigation of the pain conditions, interventions and patient flow of chronic pain patients referred to the social worker of the HUCH multidisciplinary pain clinic. A quantitative study was carried out based on medical records. The data sources used were the medical records at the Meilahti Hospital and the hospital database. Data on 55 patients referred to the pain clinic’s social worker between September 1st, 1999, and December 31st, 2000, were obtained from the medical records of the pain clinic. During this period a total of 556 patients were referred to the pain clinic.

The variables analyzed were age and gender, conditions causing pain, interventions, duration of pain, pain intensity, pain-related disruption in everyday life, psychiatric co-morbidities, referring medical unit, outside care providers, post-treatment care providers and health habits of the patient.

Patients’ conditions were classified using ICD 10. We examined the primary diagnosis leading to pain treatment, which was obtained from the patient charts. If the treatment was not terminated, the diagnosis used for the study was the last diagnosis with pain-related data in the medical records. The diagnoses fell into 17 classes but the data were grouped into 4 categories to simplify the analysis. The categories used were:

group F, persistent pain disorder and painful conditions suspected to be of psychiatric origin,

group G, neurological diseases,

group M, musculoskeletal diseases,

other conditions.

Another variable was the pre-treatment evaluation of pain intensity through the visual analogue scale (VAS). The intensity of pain was classified into four categories according to VAS scores: 1–3 (mild), 4–6 (moderate), 7–8 (severe) and 9–10 (unendurable). Patients were assessed on this scale at referral to the pain clinic using either a preliminary pain questionnaire or by describing the intensity of the pain in terms of the most intense and least intense pain experienced by the patient to date. We also recorded which everyday activities the pain interfered with. The activities included in the study were mobility, housework, recreation and sleeping. The duration of pain prior to visiting the social worker was recorded. We also recorded if the source of pain was injury or disease. Injuries were further divided into recreational and occupational accidents. Treatments received by the patients were recorded. The referring medical units and the possible provider of post-treatment care were also recorded.

Mental co-morbidities that the patients were diagnosed with were recorded. A psychiatric diagnosis was accepted only if made by a psychiatrist. If made by any other Medical Doctor, it was recorded as a “no diagnosis”. The medical records were searched for possible suicidal intents, which was classified into three categories: (1) suicidal intent, (2) no suicidal intent and (3) suicidal intent unknown. The patient was recorded to have “no suicidal intent” only if this was explicitly expressed. If there was no record of suicidal thoughts, the patient was categorized as “suicidal intent unknown”.

Regarding general health habits, we recorded obesity evaluated by the physician, and substance abuse (alcohol, tobacco or drugs). The assessment of the use of alcohol was based on self-reporting.

Some of the variables used were multi-response variables, in which a variable could be expressed with multiple values. The data were presented on bar charts based on frequency distribution.

3 Results

3.1 Source of subjects, outside care providers, treatments and after-treatment care

During the study period, the social worker saw 55 patients, 29 of which were women and 26 men. The mean patient age was 45 years, with a median age of 44 years. Two of the patients were younger than 30 and 23 were over 51 years of age (Fig. 1).

Fig. 1

Age distribution of patients referred to social worker, n = 55.

The majority of patients were referred to the pain clinic by municipal health centers. Almost as many patients were referred by other HUCH clinics. The third largest number of referrals came from the private health care sector (Fig. 2). Municipal health centers made 40% of male and 20% of female referrals. HUCH clinics referred 24% of male and 40% of female patients. Private health care made 20% of female and 12% of male referrals. Referrals made by other health care units for male and female subjects constituted 20% and 8%, respectively. Occupational health care referred 12% of the female patients but no male patients.

Fig. 2

Source of patients referred to social worker, n = 55.

Data on outside interventions during the treatment at the pain clinic were only suggestive since the data were not always available. Presumably, a majority of patients also attended primary health care. Reliable data on other therapies could only be obtained for patients treated in the Meilahti hospital. Data on treatments administered at other HUCH clinics obtained from medical records were also comparatively reliable. The number of patients treated in other HUCH clinics was 37. The number was high due to the fact that physicians at the pain clinic often referred patients to a specialist for consultation. Pharmacotherapy was the most prevalent treatment method at the pain clinic, and it was received by all patients (Fig. 3).

Fig. 3

Treatment of patients referred to the social worker, n = 55.

Twenty-three of the patients received treatment at municipal health centers, seven in other hospitals, and four in occupational health care during their treatment at the pain clinic. Eighteen of the patients were treated at private sector services, most of which were private rehabilitation facilities in which the Social Insurance Institution of Finland subsidized the therapy. Thirteen patients were treated at outpatient mental health units and had in some cases received psychiatric therapy already before the referral to the pain clinic. The post-treatment care of the pain clinic’s patients was mainly provided by primary health care services (Fig. 4).

Fig. 4

Post-treatment care of patients referred to social worker, n = 55.

3.2 Description of pain

All patients in the present study suffered from chronic pain. In 18 patients, the duration of pain was under 3 years. In 17 of the patients, pain had persisted for 4–6 years, and in 20 patients for over 7 years. No difference was found in the duration of pain between men and women. At referral, data on the intensity of pain were frequently missing (Fig. 5). Data on the most intense pain score were missing in the case of 31% of the patients. Two percent of the patients described the most intense pain as moderate, 18% reported severe and 49% unendurable pain. Data on the least intense pain score were missing in the case of 36% of the patients. The least intense pain was moderate in 16%, severe in four and unendurable in seven of the patients. The data on the post-treatment pain score could not be included in the study since it was missing from almost all medical records at the pain clinic. The expectation of pain reduction during the treatment at the pain clinic was recorded for only nine percent of the patients.

Fig. 5

Current pain VAS intensity of patients referred to social worker, n = 55.

For the majority of patients, pain caused difficulty in movement. Pain also interfered with housework and recreation in two thirds of the patients. In half of the patients, pain caused sleeping disorders (Fig. 6).

Fig. 6

Activity interference by pain of patients referred to social worker, n = 55.

Patients referred to the pain clinic’s social worker had not benefited greatly from previous interventions. In half of the patients, previous treatment had been non-effective or had even aggravated the pain (Fig. 7).

Fig. 7

Outcome of previous treatment of patients referred to social worker, n = 55.

Causes of pain were categorized into disease and injuries. The main cause of pain was found to be disease (Fig. 8). There was no gender difference in the occurrence of disease and injuries.

Fig. 8

Causes of pain in patients referred to social worker, n = 55.

The largest disease group was musculoskeletal diseases, afflicting twenty-three patients. The same number of patients suffered from neurological and sensory nervous system diseases. Four patients suffered from persistent somatoform pain disorder and one patient did not fall into any of these categories. The largest disease category among men was musculoskeletal diseases, and among women neurological diseases (Table 1). The diagnoses were spread evenly among the age groups. The average duration of treatment at the pain clinic for the subjects was 7.6 months, with a median of 6.0 months (Fig. 9). Usually the patient was referred to a social worker relatively early in the course of treatment at the pain clinic.

Table 1

Subjects’ pain diagnoses (ICD 10 classification) in patients referred to the social worker.

Number of patient	Diagnosis	ICD 10 code	Number of patient	Diagnosis	ICD 10 code
1	Nerve root and plexus compressions in intervertebral disc disorders	G55.1	29	Lumbar and other intervertebral disc disorders with radiculopathy	M51.1
2	Causalgia	G56.4	30	Other specified mononeuropathies	G58.8
3	Other chronic pain	R52.2	31	Dorsalgia, unspecified	M54.9
4	Persistent somatoform pain disorder	F45.4	32	Lumbar and other intervertebral disc disorders with radiculopathy	M51.1
5	Lesion of ulnar nerve	G65.2	33	Migraine with aura	G43.1
6	Lumbar and other intervertebral disc disorders with radiculopathy	M51.1	34	Lumbar and other intervertebral disc disorders with radiculopathy	M51.1
7	Brain stem stroke syndrome	G46.3	35	Algoneurodystrophy	M89.0
8	Lesion of plantarnerve	G57.6	36	Primary arthrosis of other joints	M19
9	Postlaminectomy syndrome, not elsewhere classified	M96.1	37	Concussion and oedema of cervical spinal cord	S14.0
10	Syringomyelia and syringobulbia	G95.0	38	Low back pain	M54.5
11	Atypical facial pain	G50.1	39	Myalgia	M79.1
12	Chronic post-tarumatic headache	G44.3	40	Postlaminectomy syndrome, not elsewhere classified	M96.1
13	Polyneuropathy, unspecified	G62.9	41	Persistent somatoform pain disorder	F45.4
14	Other spondylosis	M47.8	42	Disease of facial nerve	G51
15	Lesion of ulnar nerve	G56.2	43	Cervical intervertebral disc disorders with radiculopathy	M50.11
16	Algoneurodystrophy	M89.0	44	Thoracic scoliosis	M41.3
17	Diabetic polyneuropathy	G63.2	45	Other post-operational nerve lesion	G97.8
18	Pain in limb	M79.6	46	Lesion of lateral popliteal nerve	G57.3
19	Tension-type head ache	G44.2	47	Persistent somatoform pain disorder	F45.4
20	Other specified dorsopathies	M53.8	48	Diabetes mellitus with multiple complications	E10.7
21	Tension-type head ache	G44.2	49	Lateral epicondylitis	M77.1
22	Other specified intervertebral disc degeneration	M51.3	50	Other subarachnoid haemorrhage	I60.8
23	Radiculopathy	M54.1	51	Lesion of femoral nerve	G57.2
24	Mononeuropathy of lower limb, unspecified	G57.9	52	Other spondylosis with radiculopathy	M47.2
25	Meralgia parestehica	G57.1	53	Rotator cuff syndrome	M75.1
26	Entesopathy, unspecified	M77.9	54	Spinal stenosis	M48.0
27	Lesion of radial nerve	G56.6	55	Atherosclerosis arteries of extremities	I70.2
28	Spinal instabilities	M53.2

Fig. 9

Duration of treatment of patients referred to social worker, n = 55.

3.3 Health habits

Twenty-four percent of men and forty-eight percent of women in this sample were overweight according to the physician’s assessment. The prevalence of obesity was highest among patients aged 51–65. The condition was found in almost half of the patients in this age group.

Data relating to substance use was obtained from medical records based on patient self-reporting. Alcohol use was coded as heavy if the patient reported that his/her alcohol use was or had been heavy. Most patients reported that they abstained from alcohol or used it moderately. Less than half of the patients (n = 26) reported total abstinence from alcohol or other substances. One patient was a substance abuser (tobacco and heavy alcohol and medicine abuse). There were no known drug-abusers in the sample (Fig. 10).

Fig. 10

Substance use of patients referred to social worker, n = 55.

3.4 Mental health and suicidal intents

Slightly over half of the patients (n = 26) had received psychiatric consultation either at the pain clinic or in some other setting. Most often the patients had been diagnosed to suffer from depression by a psychiatrist (Fig. 11). A total of 55% of patients in this sample had a psychiatric diagnosis. Depression diagnosed by a psychiatrist was found in 75% of patients with pain disorder, 59% of neurological patients and 30% of patients with musculoskeletal diseases. Over half of the patients in this sample had had a least one psychological consultation (Fig. 12).

Fig. 11

Psychiatric diagnosis of patients referred to social worker, n = 55.

Fig. 12

Psychological consultation of patients referred to social worker, n = 55.

Suicidal intents were very common among patients included in this sample (Fig. 13). Over a third of the patients had reported suicidal intents to the hospital staff. Some of the patients had attempted suicide, but medical records contained no further data on these events. Fifty-two percent of men and 16% of women had thought about suicide. Of the patients who had thought about suicide, 65% had been diagnosed with depression by a psychiatrist. Thirty-five percent of patients with musculoskeletal diseases and 27% of patients with neurological conditions had experienced suicidal thoughts. Thirty-eight percent of the patients with musculoskeletal diseases and 65% of patients with neurological conditions also had a psychiatric diagnosis.

Fig. 13

Suicidal intents of patients referred to social worker, n = 55.

4 Discussion

The objective of the present study was to describe what kinds of chronic pain conditions the patients referred to the social worker at the multidisciplinary pain clinic had. The results of this study cannot be extrapolated to all chronic pain patients of the clinic since the sample consisted of referrals that had been screened by the pain clinic staff. International comparison can also not be made, since to our knowledge, no literature has been published on this. Other studies comparing diagnoses has not been made with other clients of the pain clinic. In brief, two fifths of our patients suffered from musculoskeletal conditions, two fifths from pain relating to neurological diseases, and in only two patients pain symptoms were classified as mental disorders, e.g. somatoform disorder (Table 1). The remaining ten percent of the patients had miscellaneous pain conditions. A comparison with the findings of other studies concerning the diagnosis distribution at multidisciplinary pain centers suggests that the diagnosis distribution among the clients of the social worker at the pain clinic is similar to the distribution of diagnoses at Scandinavian pain centers in general [10,11].

In the Finnish health care system, it is important for the social worker to know what a patient has been diagnosed with. For example, reimbursement for medicines and rehabilitation depends on the diagnosis. Sickness allowance is also partly dependent on the patient’s diagnosis. Moreover, the diagnosis is important with a view to intervention and in understanding the patient. Thus, the social worker has to be aware of the patient’s diagnosis as the diagnosis itself determines what measures the social worker can take to help the patient to cope.

Most clients of the pain clinic’s social worker were referred to the pain clinic by Health Centers. Gender distribution regarding the referring unit was interesting. HUCH clinics referred more female than male patients. None of the male referrals came from occupational health care. This may indicate that male patients were not working, but on the other hand, exact information on the professional status of the patients was not recorded. We have seen no previous research about where those patients who are referred to pain clinic social worker originally come from to a pain clinic. So, we cannot state if the proportion of referrals to the social worker from other clinics or primary health care is high or low in international or national comparison. It seems, however, that pain treatment in the referring units was relatively ineffective in these patients, since almost two thirds of the patients reported that the pain had either remained unchanged or even increased despite the treatment attempts prior to the referral to the HUCH pain clinic.

During their treatment at the pain clinic, patients were also treated by many other treatment providers such as other clinics of the university hospital, in municipal health centers and/or private sector facilities. In other words, pain patients referred to the social worker received a wide variety of other health care services, even when they were patients of the HUCH pain clinic. Patient referrals and several consecutive treatments may reflect the complexity of chronic pain management that is difficult to address in a nonspecialty treatment setting. Many of the patients referred to the social worker received such a vast amount of treatments and tests that these inexorably consumed a large part of the patients’ time. Some patients also demanded to have new, unnecessary tests and ineffective treatments in an attempt to legitimize their disability. We are not aware of previous research into the incidence of simultaneous, overlapping treatment in the patients of multidisciplinary pain clinics, so such overlapping treatment in this sample cannot be compared to other findings. In any case, the social worker in a pain clinic has to be aware of the existence of other treatment providers and the possibility of other social interventions initiated in other treatment units.

The university pain clinic has aimed to keep the treatment period short but still 15% of the patients in this sample had received treatment at the pain clinic for over a year. This indicates that the treatment of patients referred to the social worker was difficult and required long-term specialty care that could be provided by the pain clinic. This was also suggested by the high incidence of severe pain. Of those patients whose intensity of pain had been recorded, over two thirds had a VAS score of over 5. This level of intensity is similar to that reported by other Scandinavian pain centers [10,11]. Chronic pain greatly interfered with all areas of life of the patients in this sample. The areas examined in this study were mobility, housework, recreation and sleeping. Pain had interfered with all of these areas in over half of the subjects. These findings are in line with previous work that has shown that chronic pain impedes activities to a high extent [10,11,12].

Close to one fourth of the patients abused substances. Twenty-two percent of the patients reported current or previous heavy consumption of alcohol. This percentage is significantly higher than in the Finnish population overall, of which 16 percent have an alcohol problem [13]. On the other hand, the observed frequency of alcohol problems is in line with previous observations of Hoffman et al. [14], who found that chronic pain patients at the Åre hospital fulfilled the characteristics of alcohol or drug addiction. Similarly, the laboratory tests of 24% of patients with chronic low back pain have indicated heavy alcohol consumption [15]. Katon et al. [7] reported that as many as 40% of chronic pain patients have suffered from alcohol abuse at some stage of their illness. Our sample also seems to suggest that a fairly large part of chronic pain patients referred to a social worker are, or have previously been, heavy users of alcohol. The study included patients with possible combined alcohol and drug abuse, making the data of this sample non-comparable to other research [7]. Substance abuse should nevertheless always be assessed and intervention started as a part of the treatment, if necessary. Heavy alcohol use can be assessed using, for example, the AUDIT questionnaire developed by WHO [16]. In this test the patient answers to a short set of 10 questions considering use of alcohol, tobacco and drugs. The use of this test might be advisable even as a routine assessment. In any case, alcohol abuse is a problem that the social worker is very likely to encounter in pain centers. This may require that the social worker actively refers the patient to substance abuse counseling or rehabilitation programs.

Weight problems also seem to be common among patients referred to the social worker. Almost half of female patients were obese. Obesity-related problems among pain center clients have not to our knowledge been studied nationally or internationally. In the general Finnish population, about one fifth of working men and women were obese and almost one third of women and about one fifth of men aged 65 or over had a body mass index of 30 or over [1], which shows that our sample was similar to the population in general.

Many patients with pain are mentally strained and depressed. This sample suggests that over half of pain clinic patients referred to the social worker have problems with mental health. Forty-five percent of the subjects had been diagnosed with depression. These findings align with a Canadian study of a sample of pain center patients (n = 105), of which 40% reported depression [17]. The Canadian study was based on patient self-assessment using a symptom questionnaire, while our study included only depression diagnoses made by a psychiatrist; this may account for the difference in incidence at least partially. The incidence of depression in our sample is significant considering that Katon et al. [7] indicated a 32% incidence rate of depression in a sample of patients with chronic pain, and similarly, Wilson et al. [9] reported a depression rate of 27% among patients with chronic musculoskeletal pain. In other words, it seems that referrals made to the social worker consisted of a high degree of patients with depression. Of our patients with neurological and musculoskeletal diseases, 59% and 30% respectively, had a depression diagnosis made by a psychiatrist. This result suggests that depression is associated more with neuropathic pain than musculoskeletal pain. On the other hand, suicidal thoughts were present in about one third of patients whose chronic pain was caused by musculoskeletal disease and only in about one fourth of patients with neurological diseases, contradicting the result relating to psychiatric diagnosis. We have not seen similar findings published in previous work, which is why the confirmation of this observation requires more research. All in all, our sample indicates that a social worker must be prepared for interacting with patients that are exhausted and lacking initiative. The results show that a social worker should look for depression-related symptoms so that patients with chronic pain can be identified for possible untreated depression.

Suicidal intents were common among patients with chronic pain, since a third of the patients in our sample reported them to the staff. Of those with suicidal intent, two thirds had depression diagnosed by a psychiatrist. The observed frequency of suicidal ideation aligned with studies into chronic pain patients presented previously [18]. Our study supports the observation made by Fisher et al. [19], that suicidal ideation is associated with depression

The data of this study were not primarily intended for research but rather secondary data that were originally collected for clinical work. Therefore, the present study was hampered by insufficiently recorded data that often occurs in clinical work. Even clinically relevant data such as treatment efficacy assessment in terms of numerical parameters, even pain ratings, was almost systematically lacking. Data on substance use was also often lacking in the medical records, even though this information is essential in choosing medical treatment. Generally, failing to record clinically relevant data is an unfortunate, common phenomenon that lowers the standard of health care [20]. Therefore, several very important and interesting questions, such as, how our subjects differed from other pain clinic patients, could not be properly answered. Furthermore, the present data reflect the situation of only one multidisciplinary university pain clinic (the only in Finland at the time) and consist therefore of a relatively small number of subjects.

When counseling patients with chronic pain, the social worker should pay attention to evaluating depression, assessing substance use and possibly referring patients to substance abuse counseling rehabilitation programs depending on the patients’ motivation. Patients may also be inclined to supply the social worker with different information than to other health care staff, which may help in planning the treatment regime and carrying it out in practice. Early consultation with a social worker is highly advisable. Good co-operation with the social services and other health services is another important factor for a successful intervention; after all, many patients receive care from several facilities simultaneously or are being transferred for post-treatment care to some other facility. This requires that the social worker of a pain center has an excellent and practical knowledge of the social welfare and service systems.