Issues Magazine

National Pain Strategy: Pain Management for All Australians

By National Pain Summit Initiative

Australia’s National Pain Strategy was developed amidst a growing awareness of the many costs of pain to individuals and communities.

One in five Australians, including children and adolescents, will suffer chronic pain in their lifetime and up to 80 per cent of people living with chronic pain are missing out on treatment that could improve their health and quality of life. The High Price of Pain report, conducted by Access Economics in collaboration with the MBF Foundation and the University of Sydney Pain Management Research Institute, estimated that chronic pain costs the Australian economy $34 billion per annum and is the nation’s third most costly health problem.

Yet a person with chronic pain – that is, constant daily pain for a period of three months or more in the past six months – faces the following:

  • their condition is not officially recognised as a disease or a public health issue;
  • their family, friends, employers, schools and health professionals will often not believe they are in pain;
  • many health professionals will have received little or no training in how to treat their condition;
  • they may have to wait more than a year for an appointment at a service that can help them;
  • they have little access to community-based support;
  • their productivity at work may be lowered, which frequently leads to unemployment and impoverishment; and
  • they are personally likely to carry more than half the total economic cost.

People with chronic pain are at substantially increased risk of depression, anxiety, physical deconditioning, poor self-esteem, social isolation and relationship breakdown.

Children and adolescents with chronic pain are absent from school more often than their peers, and participate in fewer sporting activities. They may never reach their full academic or vocational potential.

Their reduced physical function and mobility can lead to loss of independence, and they may not be diagnosed and treated for social anxieties that may have contributed to, or result from, their condition.

People with cancer-related pain have their own particular needs which are often not well met, despite effective techniques being known to relieve their burden.

Acute pain – a normal, time-limited response to trauma, surgery or other “noxious” experience – also continues to be poorly managed.

The National Pain Strategy, aimed at acute, chronic and cancer-related pain, is the result of collaborative work of health professionals, consumers and funders, who agreed that an integrated approach was needed to improve care for all types of pain.

The National Pain Strategy and the National Pain Summit were led by the Australian and New Zealand College of Anaesthetists (ANZCA), the Faculty of Pain Medicine (FPM), the Australian Pain Society (APS) and the consumer group Chronic Pain Australia (CPA), in collaboration with inaugural supporters, MBF Foundation and the University of Sydney Pain Management Research Institute. Unencumbered assistance was provided by Janssen-Cilag, Mundipharma, Pfizer Australia, CSL Biotherapies, Merck Sharp & Dohme, Medtronic, iNova Pharmaceuticals, Eli Lilly Australia, Boehringer-Ingleheim, University of Sydney School of Medicine, University of Sydney Northern Clinical School and Mr Alex Carmichael. These organisations and individuals were not involved in developing the Strategy.

A series of Working Groups developed the first draft of the National Pain Strategy, which was then brought to a Leaders’ Meeting involving key stakeholders, and further developed by a series of Reference Groups. The groups comprised representatives of all primary health care disciplines, pain specialists, other relevant medical specialists and consumers. The subsequent draft was released for public and stakeholder consultation in October 2009 and revised prior to the National Pain Summit in March 2010.

The Summit’s 200 delegates, representing health professionals, consumers, industry and funders, unanimously supported the National Pain Strategy and agreed on the priority objectives (see box, page 35).

The Strategy is offered at a time of national health reform, which, if implemented with the needs of people with pain in mind, could deliver many of the changes needed to improve outcomes. The Strategy is also aligned with the recommendations of the Prescription Opioid Policy, published in 2009 by the Royal Australasian College of Physicians.

This is a remarkable opportunity to reduce the suffering, and the cost, of pain in Australia.

The Case for Change

Worldwide, governments are becoming aware of the huge impact chronic pain is having on their communities. Ageing is associated with an increasing burden of painful pathology, the magnitude of which will rise with the ageing of Australia’s population.

About one in five of the increasing number of cancer survivors experience chronic pain, further adding to the overall burden.

There are potentially vast gains to be made through prevention, community awareness, early intervention, and better access to pain management services. An important facilitator of this is the fact that chronic pain is increasingly recognised as a disease entity by the relevant international bodies. This will ease the incorporation of chronic pain into disease classification systems and allow its burden on healthcare systems to be measured on an ongoing basis.

Acute pain associated with surgery, trauma and other conditions can result in adverse outcomes, including the risk of progression from acute to chronic pain. Strategies for improved management of acute pain and early recognition of patients at risk of developing chronic pain offer important preventative options in decreasing the prevalence of chronic pain.

In the case of cancer pain, less than 50 per cent of patients may receive effective relief, and acute pain is often similarly undertreated. This is despite the capability of current techniques to relieve more than 90 per cent of both types of pain. For chronic pain, less than 10 per cent of patients gain access to effective management, whereas up to 80 per cent could now be effectively cared for. In the first international study on chronic wounds, pain was identified as the worst symptom overall, with 40 per cent reporting that pain at dressing change was the worst part of living with an ulcer. Geographical issues are also of concern as people living in regional, rural and remote areas, especially Aboriginal and Torres Strait Islander people, generally have even less access to evidence-based pain services and community support.

It is particularly difficult for people with chronic pain to obtain effective care and support because chronic pain is poorly understood by the general community, including many health professionals. Acute pain is understood by all to arise in damaged tissues. However in chronic pain, the pain arises because of neuroplastic changes in the central nervous system. This is very different to acute pain, and represents a disease in its own right. Chronic pain may follow an episode of acute pain, and thus may be triggered by tissue damage in the first instance, but the disease process is fundamentally different in physiological terms. Moreover, chronic pain does not always originate in acute pain. It has many causes and sub-types.

Changes in the central nervous system may develop during a transition phase from acute to chronic pain. Encouragingly, we already have treatments that can prevent this transition. Some established cases of chronic pain may also be treated by targeting neuroplasticity in the central nervous system; in others, pain can be reduced, but not eliminated. Pain reduction may have general systemic benefits; for example, there is a relationship between pain, stress and delayed wound healing.

Even when pain cannot be taken away, however, its effects on daily living can be minimised by means of a wide range of pain management methods. The real task is to increase access to such treatments, and to address the social and cultural determinants of the pain experience.

In children and adolescents, chronic pain and recurrent pain (such as recurrent abdominal pain and headache) may be a manifestation of social anxieties, learning problems and difficulties in coping with emotion. Early intervention can result in resilience, improved academic performance and self-esteem, increased vocational potential and reduced disability. Learning coping strategies early in life through effective pain management may be helpful when faced with adversity later in life.

Expert consensus and a growing body of research says that best-practice pain management often requires coordinated interdisciplinary assessment and management involving, at a minimum, physical, psychological, and environmental risk factors in each patient. This is the model of care offered in specialist multidisciplinary pain clinics. But these clinics have unacceptably long waiting lists, and are poorly integrated with primary health care and community-based services.

At the same time, current reimbursement and insurance arrangements are such that outmoded treatments with limited evidence of efficacy, including some invasive procedures, are often favoured over less invasive treatments with evidence of efficacy. Some treatments provided are not based on evidence, but funding. This risks overtreatment by inappropriate methods and therefore additional costs for sub-optimal outcomes.

In addition, while community-based self-management programs have been shown to be effective for other chronic conditions such as arthritis, there has been no infrastructural funding for such programs in relation to chronic pain.

Australia is, in many ways, a world leader in pain management. Pain Medicine and Palliative Medicine are established in Australia as independent medical specialties, and our research and education programs are internationally recognised. The need is to translate what we know about what works into effective delivery of pain management across the healthcare system.

Reproduced with permission from Painaustralia’s National Pain Strategy Executive Summary. References available at www.painaustralia.org.au/the-national-pain-strategy/national-pain-strate...

Painaustralia’s website, www.painaustralia.org.au, provides a range of resources for consumers and health professionals.