“30 years of DGS – and still far from the finish line”

Interview with Dr. Gerhard HH Müller-Schwefe, President of the German Society for Pain Medicine (DGS)

Dr. Müller-Schwefe, the German Pain Society (DGS), which has been advocating for pain patients for 30 years, demands that comprehensive and adequate pain therapy services finally be guaranteed throughout Germany. How can this be achieved?

Müller-Schwefe: We currently estimate that there are approximately 15 to 17 million patients in Germany suffering from chronic pain, and that around 10 percent of them suffer from severe, highly problematic pain. Based on this, we urgently need a needs assessment to ensure the care of chronic pain patients. The statutory health insurance associations are responsible for planning the population-based need for specialists and general practitioners.

We know precisely how many surgeons, anesthesiologists, internists, general practitioners, and orthopedists we need per 100,000 inhabitants. However, since pain medicine is not a recognized specialty and is currently only an additional qualification, there is no reliable planning for the needs of pain patients. Continuity of patient care is also not guaranteed. For example, if a general practitioner specializing in pain medicine ends their contract with the national health insurance system and cannot find a successor with pain management qualifications, then pain therapy in that practice ceases. This can lead to a situation where suddenly 400 or 800 patients with chronic pain have no one to turn to.

How many pain specialists do we need?

Müller-Schwefe: Assuming that a pain specialist can carefully care for 300 patients per quarter, this translates to a population-based need of approximately one pain specialist for every 15,000 patients. If we fail to establish pain medicine as a recognized medical specialty, the care of pain patients will remain precarious, and the already very long waiting times will persist due to this shortage.

What are the average waiting times for pain patients before they can get an appointment with a pain specialist?

Müller-Schwefe: This varies somewhat regionally. In most centers, waiting times range from three weeks to nine months, tending towards nine months; three weeks is rather the exception. The waiting time depends, among other things, on the diagnosis. Tumor patients and trigeminal neuralgia patients, i.e., those with the most severe pain conditions, get an appointment more quickly; others have to wait longer. This, in turn, conflicts with patients' right to adequate medical care. The German Basic Law guarantees the right to physical integrity. Thus, failure to provide pain relief can constitute bodily harm.

What, in your opinion, distinguishes a pain specialist – both professionally and personally?

Müller-Schwefe: Physicians specializing in the diagnosis and treatment of patients with chronic pain conditions require a wide range of skills, including completed specialist training in a clinical field and theoretical knowledge of how pain becomes chronic and which treatment approaches are effective. Their training should reflect the complexity of chronic pain conditions, meaning it should cover functional orthopedic, neurological, psychological, psychiatric, anesthesiological, and pharmacological aspects.

In addition to the specialized knowledge defined in advanced training for pain therapy, they require a considerable degree of empathy to deal with and connect with the most challenging patients in the healthcare system. These individuals' lives often consist of a series of catastrophes: disrupted social relationships, job loss, partnership problems, and even separation. Often, these patients have lost trust because they have experienced their perception of chronic pain not being believed. Regaining this trust requires a high degree of empathy and communication skills. Pain therapists also need a network to offer their patients interdisciplinary support, in accordance with the model of multimodal pain medicine.

Why is the introduction of the specialist title "Pain Medicine" failing?

Müller-Schwefe: The German Medical Association currently tends to favor reducing the number of specialist titles and merging specialties rather than creating new ones. Furthermore, there are concerns that individual specialties could lose areas of care. This concern is unfounded. I believe we can treat pain patients efficiently if we have appropriately trained physicians. It wouldn't cost any more money either, because ineffective treatment is the most expensive treatment of all. We, the German Society for Pain Medicine and the patient organization German Pain League, will continue to work together to implement patients' right to adequate care.

What can politics contribute?

Müller-Schwefe: I personally believe that this issue must be addressed at the highest political level. The Federal Ministry of Health and the Federal Joint Committee must take up this matter and vehemently demand adequate care. Otherwise, the inertia and particular interests of the medical specialties will outweigh the need to provide adequate care for pain patients. The Ministry of Health is the supervisory authority for the National Association of Statutory Health Insurance Physicians, and I believe Federal Health Minister Gröhe has an obligation to intervene on behalf of patients. We will only improve patient care if we have adequate points of contact in the form of medical care structures.

You now also offer continuing education courses for pharmacists and physiotherapists. What skills do these professional groups need in dealing with pain?

Müller-Schwefe: The incredibly large market for over-the-counter painkillers – with approximately 150 million packages sold annually – clearly demonstrates that pharmacies are often the first point of contact for pain relief. To optimally fulfill their advisory role, pharmacists therefore require fundamental knowledge of the mechanisms of chronic pain development, as well as effective pharmacological and non-pharmacological strategies. That's why we train pharmacists and their teams and certify them as competence pharmacies. The certification is valid for one year.

Physiotherapists have incredibly close contact with patients suffering from chronic pain. Therefore, it is crucial for this professional group to understand how pain becomes chronic and what factors, including psychological ones, play a role. We train physiotherapists to recognize fear-avoidance strategies and teach them how to help their patients learn techniques they can use to help themselves.

How do you assess the state of palliative care provision? What needs to be done in this area?

Müller-Schwefe: One of the cornerstones of adequate palliative care is appropriate pain management. Here, too, there is still enormous room for improvement, because whether patients find suitable care structures in their final stages of life depends far too much on chance. I'm on the board of an inpatient hospice, and it took us ten years to raise the money to open the hospice. Every year, we have to finance 10 percent of the costs through donations to keep the hospice running. There are significant shortcomings in this area in Germany. For example, we often see that—due to a lack of infrastructure—patients are transferred from hospitals to nursing homes. But these facilities are not equipped to care for patients in their final stages of life with problematic and painful illnesses. This is a catastrophe, but unfortunately, it doesn't happen publicly. Otherwise, there would be a huge outcry, because death and dying affect everyone.

German Society for Pain Medicine (DGS)

The German Pain Society (DGS) is the largest European professional society dedicated to improving the understanding, diagnosis, and treatment of chronic pain, with more than 4,000 members. It is organized nationwide in over 120 regional pain centers, which host interdisciplinary pain conferences. The DGS's primary goal is to improve the care of people with chronic pain. This can only be achieved by establishing algology (the study of pain) as a medical discipline. This includes quality assurance in pain medicine through the establishment of treatment standards and the improvement of basic, advanced, and continuing education in pain diagnostics and pain therapy for physicians of all specialties. The DGS publishes the Pain Therapy Guide, which lists all its members. Together with the German Pain League (Deutsche Schmerzliga e.V.), the DGS organizes the annual German Pain and Palliative Care Day in Frankfurt am Main.