Pain management in liminal spaces.

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Chronic pain (CP) is estimated to affect one-third of the UK population [Fayaz 2016] and presents major personal, economic, and societal challenges [Kyu 2018]. There are deficiencies in contemporary healthcare provision for people living with CP (PLWCP), with efficacy of established treatment approaches being challenged [NICE NG59 (2016), NG10069 (2021), Williams 2020]. Treatments for PLWCP, typically informed by the biopsychosocial (BPS) and psychological approaches, are widely accepted in healthcare [Mescouto 2020, Denneny 2020]. However, the BPS approach has been challenged as reductionist and not person-centered [Stillwell 2019]. Misunderstandings of the term psychological fuel (mis)perceptions that CP is "all in the head" [Bransfield 2019]. This can lead to conflict between PLWCP and health care providers, marginalisation, and stigma [Farr 2018, Boulton 2019]. Furthermore, social determinants of health (SDoH) have until recently been largely ignored in pain research, resulting in underexplored inequalities of care [Moscrop 2020]. Only 2% of PLWCP can currently access pain services [Burke 2020] and many are usually discharged with continuing pain. Pain services advocate skills development for independent pain "self-management" yet no consensus definition for self-management exists (Walumbe, pers. com.). Pearce (2015) argues that self-management requires a collaborative approach with health-care systems and is not the sole responsibility of the individual. Advocacy organisations including Chronic Pain Coalition and ARMA support this proposition and request regular review appointments. Ongoing healthcare reviews are not supported with evidence, are unsustainable, and potentially preserve a clinical hegemony where existing inequalities remain unaddressed.