Interview: France works to close its pain management gap

Dr. Christian Pommier, Saint Joseph General Hospital, Lyon, France. Photo: Michael Cosgrove

Slow to adopt pain management policies, France is finally beginning to catch up through a national strategy. Michael Cosgrove interviews one of France’s leading pain management specialists.

Once notorious for refusing to even consider treating pain as an essential part of the patient rehabilitation process, France is now beginning to make up for its shortfall in pain management research and implementation.

Dr. Christian Pommier is head of the Pain Management Unit in Lyon’s prestigious and innovative Saint Joseph General Hospital. An anaesthetist by training, he believes that pain management is an essential part of the patient healing process, and that it can only be effective if it is universally recognized as such by the medical profession, and if it involves a pluri-disciplinary approach.

Until the 1990s, treating pain was considered of secondary importance in France for reasons related to medical, cultural and religious belief.

Pommier explains the situation today, which has seen major changes in French medical attitudes towards pain management, or ‘La prise en charge globale de la douleur” as it is known here.

Pain means different things to different cultures. It is generally accepted, for example, that Judo-Christian and Muslim cultures have very different perceptions of what pain is and how it should or should not be treated; the former believing pain to be a kind of obligatory suffering which leads to redemption and the latter having a more pragmatic approach. Did these cultural factors play a role in France’s past philosophy of minimal pain relief?

Yes, they did, and they still do to a certain extent, but they do not tell the full story because they do not in themselves explain the large disparity between France and many other Western countries. The difference is that France is a European Latin country, which makes it even more Judo-Christian, and Catholic, than the others. Past efforts to take pain management seriously were disparate and badly organized, whereas Anglo-Saxon countries were developing their experiences in a rigorous manner. Even post-operative pain was neglected here until relatively recently.

It has often been claimed that research in this area has thus far been insufficient. Could you explain how pain management research and application have evolved in France over the years in that context?

In terms of research I am inclined to speak in European terms because it is obvious that individual countries do not have anywhere near the same investment capacities as, say, the United States. The problem on a European scale, on the other hand, which would be comparable to the United States, is that each country has tended to approach the subject in its own way, partially because of the cultural reasons we were discussing earlier.

France has made progress, notably in terms of more positive framework legislation which was enacted during the late 1990s and early 2000s. Bernard Kouchner – France’s health minister at the time – made notable contributions to that legislation, the effects of which are finally beginning to trickle down to hospitals in the form of more and more pain management units being set up.

The law now recognizes the patient’s right to have access to pain management care and medical staff now have a duty to administer it. There is also a specifically defined legal, moral and ethical code of conduct appended to pain management.

Saint Joseph’s hospital is a recognized leader in this field. How and why did you get involved in pain management and what started the ball rolling?

St Joseph’s was an early pioneer in pain management and I was lucky enough to get the chance to work with Dr. Latarjet, a well-known burns specialist, who created the unit back in 1981. He was an inspired man and a wonderful motivator. Like myself, he was a firm believer in the importance of the work being done in England and America, and he adopted as many of the same principles as was possible at that time when he set up his own unit.

The result today is that the unit now evaluates pain along with the patient’s own impressions, which are expressed during consultations and by using the Visual Analog Scale, which consists of a straight line beginning at ‘No pain’ and finishing at ‘Extreme pain.’ The patient draws a cross on the line between those extremes at the point which he thinks most appropriate. It’s simple but it can be surprisingly accurate. Another evaluation tool is an adapted version of the Wall & Melzak questionnaire, which is a seven page document designed to address a whole range of pain-related issues.

It is important to minimize the amount of technical and strictly medical terms used during evaluation, because not all patients understand them all well enough to select the term which is most appropriate.

The unit treats out-patients who have been referred by their doctors as well as, of course, the hospital’s own patients.

Could you describe the unit’s current organization and methods, and how they are designed to respond to your philosophy of patient treatment?

My team consists of around a dozen people, including neurologists, anaesthetists and a psychologist, as well as a general practitioner and motortherapy specialists.

It is vital in my view that pain management in France not be considered, as it was in the past, as an isolated entity within the hospital which deals with pain as if it were a separate issue from the patient’s pathologies. We liaise closely with all the hospital’s departments, from oncology to burns, and we try to find mutual solutions to all aspects of the patient’s pain, from its physical origin to the way it is experienced. In other words, I consider that pain management needs to be a pluri-disciplinarian process if it is to be successfully treated.

It is also extremely important to keep in mind in that context that pain can result in many kinds of secondary effects. Some are psychological, such as depression, others are physiological, and patients are encouraged to discuss the effects of their condition on their family relationships, which can become strained due to the stress of living with pain, loss of appetite and sleep, and even financial worries.

Those variable factors explain why a treatment pattern for one patient may not be suitable for another.

Can you give me any concrete examples of those effects?

I recently treated a patient who had lost an arm in a work accident. This case is a good example of how all aspects of pain are interwoven. Not only had he lost an arm, but he was also suffering from the psychological trauma of watching it being drawn further and further into the machine whilst he tried to pull it out with his remaining arm. He had to give up because he knew he may well lose the other arm if he reached too far into the machine.

In his case, treating the pain alone would have been insufficient as he needed specifically adapted treatment to take into account his psychological state. That treatment in turn had an incidental effect on certain treatments he was taking for the physical pain, which in turn meant that his treatment had to be progressively adapted according to his evolving condition.

This demonstrates how each case needs to be addressed individually and from all angles.

Finally, although legislation has now taken into account the importance of pain management, are you satisfied with the results? Are you getting the funding you think you should be getting?

Things could be better to be honest. France is, as you know, well known for its complicated organizational structures, particularly concerning public finances and the manner of their allocation and distribution.

My department, for example, hasn’t received all the funding that was requested for various reasons, including government funding allocations being modified by the hospital itself.

Also, I bought the book that you see on my desk quite a few years ago whilst attending a seminar in, if my memory is correct, the United States. It is called Handbook of Headache by Evans and Mathew, and it is considered to be a world reference for those with an intermediate professional knowledge of headaches and migraines and how to treat them.

Well, it was almost impossible to find it in France at that time of course and, astonishingly enough, it still is!

So progress is certainly being made, but, like anything else in life, there is always more progress to be made.

Thank you for your time and your valuable insights, doctor, and I would also like to express my gratitude for the warm and efficient reception given to me by your administrative staff.