Australia’s painful secret

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Australia has a secret, one that is shared by at least 20 per cent of the population. It is chronic pain. And it is only just beginning to be recognised as a serious medical condition in its own right – not just a symptom of another disease, writes PainAustralia Chief Executive Officer Lesley Brydon.

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Affecting one in five Australians, including adolescents and children, and one in three aged over 65, chronic pain is the most common reason people seek medical help – yet it remains the most neglected area of healthcare.^1,2
An estimated 3.2 million Australians live with chronic pain, yet up to 80 per cent are missing out on treatment that could improve their health and quality of life – due to a shortage of pain services and qualified health professionals.^3,4
People wait on average more than a year to access multidisciplinary pain services in public hospitals, with rural and remote communities most disadvantaged.⁵
According to the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists, there are only 275 pain medicine specialists practicing in Australia, who are unable to meet demand. This is supplemented by just 24 registered pain specialist training positions.
Unlike acute pain, chronic pain is not widely understood – even by health professionals. While acute pain resulting from injury, trauma or other condition is generally short-term and relatively easy to treat, chronic pain is far more complex, persisting long after the normal time of healing. In some cases, it can exist without a clear reason at all.
Commonly, people with unresolved pain ‘doctor-shop’ for years, undergoing all types of tests, in the hope of finding an accurate diagnosis and a practitioner who can provide effective treatment.
For 45-year-old Soula, it took five years to diagnose her pelvic pain condition. During that time, she was prescribed an array of painkillers and antidepressants, with every doctor telling her it was back pain.
This kind of delay is not only psychologically and emotionally damaging for the patient, but also potentially detrimental for their condition.
Left untreated, chronic pain can lead to decreased enjoyment of normal activities, loss of function, relationship difficulties and interference with work. Most insidious of all is the stigmatisation that surrounds a largely invisible condition.
For 28-year-old Amy who has degenerative disc disease, despite a marketing degree and several attempts to secure employment, she now lives at home with her parents and receives welfare payments, due to a lack of flexible workplace options and poor understanding of her condition.
Lack of timely treatment or under-treatment of acute pain can also lead to chronic pain associated with neuroplastic changes within the spinal cord and brain. After tissue or nerve damage, the nervous system can become sensitised to pain, leading to pain signals being transmitted unnecessarily.⁶
Neuropathic pain, often described as burning, painful, cold or electric shocks, is one of the most difficult forms of pain to treat and to experience. Tracy, 50, says she tried abstaining from her painkillers once, but was in so much pain from Complex Regional Pain Syndrome, she attempted suicide. She is not alone.
An Australian study in 2006, found that 21 percent of people who died by suicide experienced physical health problems that may have contributed to their death; while the Australian Bureau of Statistics reports that almost one third of adults with severe pain also have high levels of psychological distress and 20 percent have depression or other mood disorders.^7,8
Chronic pain also places a significant burden on the economy, costing Australia an estimated $34.3 billion per annum, with productivity costs of $11.7 billion and health system costs of $7 billion. It is estimated half these costs could be saved by providing effective and timely treatment.⁹
Arthritis and back problems alone account for 40 percent of forced retirements and an estimated economic burden of $4 billion a year, while chronic pain in general is the most common reason people aged between 45 and 64 drop out of the workforce.¹⁰
Despite these alarming statistics, the surprising reality is that with effective multidisciplinary treatment, chronic pain can be managed with resultant reduction in disability, improved capacity to work, and benefits to overall wellbeing and quality of life.
Multidisciplinary pain management addresses the complex physical, psychological and environmental factors that contribute to the pain experience. The multidisciplinary team usually includes a physician, nurse, psychologist or psychiatrist, physiotherapist or occupational therapist, and pharmacist who all have training in pain management; it may also include a vocational counsellor or social worker.
Although it might involve medical interventions and medications, multidisciplinary pain management is largely based on non-invasive and non-pharmacological means, and often involves Cognitive Behavioural Therapy.
Indeed, when patients with chronic pain receive the same approach to treatment that would be applied to acute pain, they experience only a 30 percent reduction in pain, on average. In addition, use of medications such as opioids alone may confer analgesic benefit, but is unlikely to result in psychological or functional improvement. ¹¹
The key goals of the  National Pain Strategy are:

• People in pain as a   national health priority


• Knowledgeable, empowered   and supported consumers


• Skilled professionals and   best-practice   evidence-based care


• Access to interdisciplinary   care at all levels


• Quality improvement   and evaluation


• Research to improve  knowledge and treatment of pain

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“Chronic pain also places a significant burden on the economy, costing Australia an estimated $34.3 billion per annum, with productivity costs of  $11.7 billion and health system costs of $7 billion. It is estimated half these costs could be saved by providing effective and timely treatment.”

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The multidisciplinary approach to pain management is a key recommendation of Australia’s National Pain Strategy, and is also endorsed by the International Association for the Study of Pain.
The National Pain Strategy provides a coordinated approach to improving pain services in Australia. An outcome of the National Pain Summit in 2010, it was developed by more than 200 health professionals, consumers and other stakeholders, who represented more than 150 organisations.
With a focus on improving access to multidisciplinary pain services across all levels of the health system, the Strategy provides a framework for the best practice assessment, treatment and management of acute, chronic and cancer-related pain.
Painaustralia is a national not-for-profit body established in 2011 to facilitate implementation of the National Pain Strategy, working with governments, healthcare professionals, consumers and other stakeholders. Considerable progress is being made in many health jurisdictions as reported in a recent review conducted by Painaustralia and reported in the Medical Journal of Australia. However a nationally coordinated approach is still needed.
New South Wales has developed a comprehensive state-wide pain plan which aims to provide access to services at the tertiary, secondary and primary care levels, as well as comprehensive resources for consumers and health professionals both online and in local libraries.
Three states, Queensland, New South Wales and Victoria have invested funds to establish a total of fourteen new regional multidisciplinary pain clinics. These clinics along with the metropolitan pain centres in these states are now collecting data and evaluating outcomes through EPPOC – the Electronic Persistent Pain Outcomes Collaboration.

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“The multidisciplinary approach to pain management is a key recommendation of Australia’s National Pain Strategy, and is also endorsed by the International Association for the Study of Pain.”

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Western Australia has funded a new paediatric pain service and has been working through existing networks to incorporate pain management strategies. The ACT has incorporated chronic pain into its Chronic Conditions Strategy 2013-2018, while Tasmania and South Australia have Steering Groups currently developing state-wide pain management plans.
Painaustralia’s work with Medicare Locals has helped build capacity at the primary care level in some areas, with GP-led teams working collaboratively to manage patients and helping to reduce wait times at public hospitals. Nurse clinics are also being developed in some areas.
An early leader in this area is Perth North Metro Medicare Local, which has been offering STEPS (Self Educative Pain Management Sessions) since 2011. The two-day program, based on a program at Fremantle Hospital, provides patients with knowledge about self-management, and how to make the best use of local primary health resources.
Hugely successful, STEPS reduced wait times at pain clinics at Royal Perth and Fremantle hospitals from up to two years to just two months, and also lowered demand for surgery and other more complex procedures. Now operating at three Medicare Locals in Western Australia, STEPS has also been adapted for other pain clinics across Australia, with assistance of the team at Perth North Metro Medicare Local.
Another key component of the National Pain Strategy is tailored education and training for healthcare professionals. There is now a range of best-practice learning opportunities, including the Royal Australian College of General Practitioners and the Faculty of Pain Medicine online pain management education program for GPs, nurses and allied health professionals.
The Pain Management Research Institute, University of Sydney provides online post-graduate courses and also offers short courses and webinar-based training tailored to the needs to primary care teams.
Despite this progress, chronic pain remains in the backwaters of health policy at the federal level. Largely a silent disease, it targets people in secret, is not talked about and remains highly stigmatised. Yet chronic pain can destroy people’s lives. It needs much greater prominence on the health care agenda.
Painaustralia’s Campaign for Pain calls upon the Federal Government to make pain a national health priority and encourages all Australians to get behind this important issue.
In it for the long haul, along with its members and supporters, Painaustralia will continue to shed light on Australia’s painful secret, for as long as it takes.
Visit www.painaustralia.org.au or www.campaignforpain.or
Lesley Brydon, Painaustralia Chief Executive Officer
A pharmacist with a background in communications and health advocacy, Painaustralia Chief Executive Officer Lesley Brydon, was formerly Executive Director of the Advertising Federation of Australia. She retired from this role several years ago with chronic pain due to advanced osteoarthritis.
As she progressed through four joint replacements, Lesley learned that there was a great deal of new knowledge emerging about pain and pain management which was not finding its way into education and training for health professionals – let alone to people living with pain. Lesley worked with leading pain expert, Professor Michael Cousins AO to coordinate the National Pain Summit and develop the world’s first National Pain Strategy, in collaboration with over 200 consumers and health professionals representing 150 organisations.
“Living with pain and with my experience in health care and communications I am probably well cut out for this job,” says Lesley. “As I see changes happening, it occurs to me that it is possibly the most useful and satisfying thing  I have done in my working life.”
About  Painaustralia
Painaustralia is a national not-for-profit network of healthcare, consumer and related organisations, formed in 2011 to facilitate implementation of the National Pain Strategy.
The Painaustralia network spans the entire pain community creating a strong alliance, which aims to help influence policy makers, funders, healthcare providers and the community to transform the way pain is understood and managed.The mission of Painaustralia is to improve the quality of life for people with pain and their families, and to minimise the burden of pain on individuals and the community.

References

1. Blyth et al. 2001 Chronic Pain in Australia: a prevalence study. Pain 89(2-3), 127-34.


2. http://sydney.edu.au/medicine/fmrc/publications/sand-abstracts/150-Chronic_ Pain.pdf


3. MBF Foundation 2007 The High Price of Pain, Report by Access Economics in conjunction with the Pain Management Research Institute – University of Sydney


4. National Pain Strategy 2010


5. Australian Pain Society 2010 Waiting in Pain


6. Cousins MJ & Gallagher RM 2011 Fast Facts: Chronic and Cancer Pain


7. Commonwealth of Australia 2006 National Activities in Suicide Bereavement Project, Department of Health and Ageing, Canberra


8. Australian Bureau of Statistics 2011 4841.0 Facts at Your Fingertips: Health: Characteristics of bodily pain in Australia


9. MBF Foundation 2007 The High Price of Pain, Report by Access Economics in conjunction with the Pain Management Research Institute – University of Sydney


10. Schofield at al. 2012 Quantifying the productivity impacts of poor health and health interventions, Health Economics, University Sydney


11. Turk DC 2002 Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin J Pain 18: 355-65


12. Cousins MJ and Brydon L 2014 Unrelieved Pain: Are we making progress? Shared education for general practitioners and specialists is the best way forward, Med J Aust 2014; 201 (7): 379-380


13. www.painaustralia.org.au/images/pain_australia/Review_of_Progress_with_NPS_IN_REVISION_9_September_WEB.pdf