Addressing Barriers to Chronic Pain Treatment in Australia

Hayley attended the 71st World Health Assembly in Geneva in 2018. She is a PhD candidate at the University of South Australia and is currently a physiotherapist at the Royal Adelaide Hospital and a pain science tutor at UniSA. 

Abstract

Chronic pain imposes a significant social and economic burden on the individual and the Australian community. There is a large gap between the volume of pain science knowledge generated through research and the application of that research in current policy and community settings. As a result, healthcare professionals do not receive adequate training in pain assessment and treatment, funding systems do not effectively meet needs in primary or tertiary care, and societal myths that encourage detrimental behaviour and increase fear and anxiety perpetuate. 

This paper will review the current state of pain management in Australia; consider international efforts to change the way the concept of pain is taught, classified and funded and; propose recommendations to align clinician and community views with a contemporary, biopsychosocial understanding of pain, with the ultimate aim of improving outcomes and reducing the economic and social impact of chronic pain. 

Policy recommendations:

1.     Recognise chronic pain as a chronic medical condition under the Chronic Disease Management Plan of the Medicare Benefits Schedule.

2.    Mandate core competencies and minimum hours of pain education training for prelicensure education for healthcare professionals.  

3.     Implement a public health campaign to destigmatise chronic pain, encouraging sufferers to learn about their pain and seek active treatment approaches. 

Context 

Chronic pain is a major health problem, affecting one in five people in Australia [1] and globally [2]. Pain persisting for longer than 3 months is termed ‘chronic’ and can present with no pathophysiological causes. Chronic back pain is the most common form of chronic pain, the leading cause of disability worldwide and one of the most common reasons for people of working age to drop out of the workforce. Each year Australia spends over $34 billion dollars on chronic pain [3]making it the nation’s third most costly health condition, ahead of cancer and heart disease. Global prevalence rates for chronic pain are shown to be rising [4], which is thought to be linked to an aging population, as the chronic pain becomes more common as age increases [5]. Considering that prevalence estimates of chronic pain show a rising trend, there is concern that the economic and social costs of chronic pain will also increase.

Chronic pain imposes wide-ranging effects on the individual experiencing it. The social consequences of persistent pain include increased work absenteeism and reduced work effectiveness [6]. Mental health is significantly affected, as people with chronic pain are at a higher likelihood of experiencing anxiety and depression than those without pain [7]and twice as likely as those without pain to suicide [8]. People experiencing chronic pain utilise health services more than people without chronic pain [9, 10]and may be prescribed opioids for pain management that are associated with an increased risk of dependency and fatality [11].

Outdated, but still widely popular, treatments for chronic pain are based on the biomedical model (i.e. attributing pain solely to biological factors) and often fail to effectively treat pain while risking the possibility of further worsening disability. Contemporary views of pain recommend treatment based on the biopsychosocial model (i.e. attributing pain to biological, social and psychological components) leading to recommendations for multidisciplinary care focusing on active treatments. These recommendations as outlined below are tailored to amending extant health policies to encompass a biopsychosocial understanding of pain. 

Recommendation 1: Recognise chronic pain as a chronic medical condition under the Chronic Disease Management Plan of the Medicare Benefits Schedule.
 

International law and advocacy


Historically, there has been global failure to recognise chronic pain as a serious chronic health problem that requires access to management akin to other chronic diseases, such as diabetes or chronic heart disease [12]. The first serious move towards change was in 2004 when the World Health Organisation (WHO) co-sponsored the first ‘Global Year Against Pain’ with the International Association for the Study of Pain (IASP). This was the first global campaign to recognise chronic pain as a public health issue and raise international awareness. In 2010, the IASP developed the Declaration of Montreal, stating that access to pain management is a fundamental human right [13]. 

As international law recognizes pain management as a basic human right, nations are ethically mandated to provide pain treatment under the right to health [14]. As such, there is a strong focus on access to pharmaceutical pain treatment and drugs like morphine and codeine have been placed on the WHO List of Essential Medicines [15]. While these drugs are undeniably beneficial for acute and surgical pain, studies have consistently demonstrated that for chronic pain they are ineffective and over the long-term can have determinantal effects including addiction [16]and opioid-induced hyperalgesia (i.e. worsening pain) [17]. International guidelines recommend chronic pain to be treated with a multi-disciplinary, biopsychosocial approach with a focus on non-pharmaceutical interventions [18].  

To improve treatment of chronic pain, the IASP encourages countries to produce their own National Pain Strategy (NPS) and published recommendations for the most desirable characteristics that it should entail [19]. Australia was the first country to respond. In 2010 a National Pain Summit was held in Canberra, resulting in the development of Australia’s proposed NPS [20]. It was promoted in 2013 with a ‘Campaign for Pain’ calling on Australian federal government to adopt the proposed recommendations. Early in 2018, the Australian government announced a small amount of funding ($150,000) for a national action plan on chronic pain management, however to date none of the aims of the campaign has been achieved. 

Proposed funding changes

The current funding system for chronic pain does not address the needs of the Australian population. While it is estimated that 20% of Australians experience chronic pain [1], only 0.18% of the population access tertiary pain management services annually [21]. If Australians with chronic pain are eligible, they will wait an excess of 6 months to access the service [21], by which time it is likely the outcome will be poorer than if immediate treatment was available [22]. An alternative, cost-effective solution is to treat chronic pain in primary care through the Medicare Benefits Schedule (MBS). 

Australia’s current Medicare system provides someone experiencing chronic pain five visits a year to healthcare professionals. There are no minimum training standards, specialised pain training requirements, nor guidelines for specific therapies to be performed by healthcare professionals during these visits. As such, in primary care settings, it is difficult for someone experiencing chronic pain to access specialised, coordinated, multi-disciplinary biopsychosocial care that is recommended as best practice care for chronic pain. 

Chronic pain should be listed under the Chronic Disease Management Plan (CDMP). The CDMP enable General Practitioners to plan and coordinate the health care of patients with chronic or terminal medical conditions. A General Practitioner would provide an initial consultation and assess suitability to enter the program, which would then provide scheduled items for group programs with up to 10 visits. Importantly, these would entail a multidisciplinary approach (psychology, physiotherapy, etc.) with a biopsychosocial focus. However, there is little benefit in translating pain treatment to primary care if healthcare professionals have limited education in pain assessment and treatment. 

Recommendation 2: Mandate core competencies and minimum hours of pain education training for prelicensure education

Improving pain education

Pain knowledge deficits among health professionals are a principal barrier to optimal pain management [13]. Yet a paucity of pain education persists in most prelicensure (entry-level) curricula globally. Australia is no exception. While some recent programs have attempted to implement pain curriculum with good success [23], there is no mandated core curriculum of pain education in health courses prior to accreditation. There is a pressing need for a coordinated response among all health curricula in Australia [24]. 

The lack of adequate pain training in prelicensure education is a global phenomenon. Reports from Canada revealed the majority of health science programs (67.5%) were unable to specify designated hours for pain education, and veterinary students were taught more about pain than medical students [25]. Similarly, in America, only four out of 104 medical schools had a pain course requirement and the cumulative number of pain teaching hours across schools ranged from one to 31 [26]. Pain education in European medical schools also falls short of what might be expected given the prevalence and public health burden of pain [27]. Considering pain is one of the most common complaints in healthcare [28], this is clearly not sufficient.

Canada, America and Germany have implemented core curriculum to remedy the lack of prelicensure education for health professionals. Canada was among the first to respond. In 2002, they used the IASP Core Curriculum to develop an integrated interprofessional pain curriculum and applied it to prelicensure education for health professionals [29]that resulted in improved pain-related knowledge outcomes in students [30]. Europe followed suit and in 2008 released The Pain Management Core Curriculum for European Medical Schools[31]. Germany adopted and introduced their own version of this core curriculum for German medical schools nationally in the same year [32]. America has noticed a similar caveat in their medical education [33]. In response, the University of Washington implemented a 4-year integrated pain curriculum between 2009-2011 and initial results have shown improved pain knowledge amongst students [34]. Following this, in 2012 the National Institute of Health funded 12 sites to become Centres of Excellence in Pain Education and give them the task of developing, evaluating, integrating and promoting pain management curriculum and resources [35].

Australia should implement similar measures to its international counterparts. Under Australia’s Health Practitioner National Law Act, setting registration standards of health professionals is the responsibility of the respective National Boards established for each profession. The Australian Health Practitioner Regulation Agency (AHPRA) supports all National Boards to achieve this and administers the National Registration and Accreditation Scheme to ensure only suitably trained practitioners are registered. To enact national change for prelicensure education, all National Boards that fall under AHPRA should ensure that accreditation for programs of study can only be achieved if a minimum standard of core pain competencies is met. An interprofessional Competency Advisory Committee should also be established to decide on Australia’s core pain competencies and may take direction from international standards [36, 37]. 

Recommendation 3:  Implement a public health campaign to destigmatise chronic pain, encouraging sufferers to learn about their pain and seek active treatment approaches.

Proposed media campaign

While the education of health professionals can help drive cultural transformation, there is also a need for a societal shift in the way the wider population conceptualises pain. Research has shown a mismatch between community beliefs about pain and current best-evidence regarding prognosis and management of pain conditions. Additionally, chronic pain with or without diagnosis is highly stigmatized [13]. Studies suggest that around 30% of pain sufferers feel that no one believes how much pain they are experiencing with one in four feeling that colleagues, employers, family and doctors were unsympathetic to their pain, did not think their pain was a problem and did not understand how their pain affects them [38]. It is unsurprising that the person in pain also questions the legitimacy of the source of pain. Studies reveal that 40% of adults who have been provided with the diagnosis of chronic pain believed there was something else, serious and undetected, causing their pain [39]. This is especially worrying considering this diagnostic uncertainty can lead to emotional distress and an increase in anxiety, depression, disability, pain intensity and pain catastrophizing [40, 41].

Public health campaigns utilise multiple forms of media and other commercial marketing techniques to promote belief and behaviour changes that will improve the health of a population. Mass media campaigns can have important effects on health care utilisation [42]. Previously successful health-related media campaigns include campaigns to increase physical activity, reduce cigarette consumption, promote cancer screening and reduce sun exposure. Targeting the population as a whole has the advantage of potentially modifying the knowledge or attitudes of a large proportion of the community at the same time, thereby providing social support for behavioural change. This is doubly pertinent to the perception of pain, as we know that social influences have the ability to modulate a pain experience (i.e. increased social support can reduce pain perception [43]).  

Australia has previously implemented a public health campaign in 1997, focusing on back pain, with great success [44]. This mass-media campaign effectively altered both community and physician beliefs and resulted in a decline in the number of workers' compensation back claims and health utilization over the duration of the campaign. Significant sustained improvements in beliefs were observed 3 and 4.5 years after the end of the campaign and cost savings were estimated to be significantly more than the cost of the campaign [45, 46]. 

The aim of the proposed public health campaign for chronic pain would be for: the general public to become better informed about chronic pain, its causes and possible consequences and what help is available for prevention and treatment; for people with chronic pain to access effective treatment and advice, and for family, friends and colleagues of people living with chronic pain to be able to provide support. The campaign would aim to promote the use of effective interventions for chronic pain and discourage ineffective ones. The focus of the campaign would be on sharing narratives of both peers who experience chronic pain and medical experts, as this combination in public health campaigns has shown to affect behaviour change [47]. The effectiveness of the campaign should be assessed, with clear outcome measures outlined prior to commencement. 

A major part of this campaign would be to address myths that perpetuate in society and shift public perceptions of the role of active self-management. Firstly, a large cohort survey of the Australian population should be conducted to determine current beliefs about chronic pain. The public health campaign will then be focussed on the beliefs that highlight a misconception when compared to current evidence. This is important because misunderstandings in the community about chronic pain can lead to maladaptive responses, which in themselves, can worsen a pain experience and further impair function. For example, the common misconception that pain is always an indicator of tissue damage can lead people to avoid moving so that they avoid feeling pain. However, evidence has consistently shown that ‘fear avoidance’ behaviour can be detrimental to recovery and result in deconditioning and worsening pain, as opposed to recommended active coping (e.g. pacing activities).

Conclusion

Increasing prevalence estimates of chronic pain demonstrate the current status quo of pain management in Australia is clearly not sufficient. Pain scientists have made significant discoveries towards effective treatments for chronic pain focusing on active, biopsychosocial-focused strategies. Despite this, healthcare professionals continue to implement outdated, biomedically-focused techniques reflecting, among other things, inadequate training. There needs to be a focus on improving the quality of pain education in tertiary institutions before healthcare professionals enter the workforce. Those clinicians then need to be able to work within a medical landscape that recognises chronic pain as a chronic disease, allowing for extended access to multidisciplinary care through the MBS. This should be coupled with a public health campaign that will provide a bottom-up approach by educating people with chronic pain about the benefits of active treatments, meanwhile enlightening the wider Australian community on the invisible and highly misunderstood impacts of chronic pain in an effort to reduce the current stigma that surrounds it. 

 

 

References

 

 

1.         Blyth, F.M., et al., Chronic pain in Australia: a prevalence study.Pain, 2001. 89(2-3): p. 127-134.

2.         Jackson, T., et al., A systematic review and meta-analysis of the global burden of chronic pain without clear etiology in low-and middle-income countries: trends in heterogeneous data and a proposal for new assessment methods.Anesthesia & Analgesia, 2016. 123(3): p. 739-748.

3.         Access Economics, The high price of pain: the economic impact of persistent pain in Australia.Sydney: MBF Foundation, 2007: p. 9-11.

4.         Vos, T., et al., Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.The Lancet, 2017. 390(10100): p. 1211-1259.

5.         Fayaz, A., et al., Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies.BMJ open, 2016. 6(6): p. e010364.

6.         van Leeuwen, M.T., et al., Chronic pain and reduced work effectiveness: the hidden cost to Australian employers.European Journal of Pain, 2006. 10(2): p. 161-161.

7.         Castro, M., et al., Comorbid anxiety and depression disorders in patients with chronic pain.Arquivos de neuro-psiquiatria, 2009. 67(4): p. 982-985.

8.         Ratcliffe, G.E., et al., Chronic pain conditions and suicidal ideation and suicide attempts: an epidemiologic perspective.The Clinical journal of pain, 2008. 24(3): p. 204-210.

9.         Blyth, F.M., L.M. March, and M.J. Cousins, Chronic pain-related disability and use of analgesia and health services in a Sydney community.Medical journal of Australia, 2003. 179(2): p. 84-87.

10.       Blyth, F.M., et al., Chronic pain and frequent use of health care.Pain, 2004. 111(1-2): p. 51-58.

11.       AIHW,Non-medical use of pharmaceuticals: trends, harms and treatment 2006–07 to 2015–16. 2017, Australian Institute of Health and Welfare.

12.       Bond, M. and H. Breivik, Why pain control matters in a world full of killer diseases.Pain Clin Updates, 2004. 12(4): p. 1-4.

13.       Cousins, M. and M. Lynch, The Declaration Montreal: access to pain management is a fundamental human right. 2011, LWW.

14.       Lohman, D., R. Schleifer, and J.J. Amon, Access to pain treatment as a human right.BMC medicine, 2010. 8(1): p. 8.

15.       WHO,WHO Model List of Essential Medicines 2017.

16.       Ballantyne, J.C. and S.K. LaForge, Opioid dependence and addiction during opioid treatment of chronic pain.Pain, 2007. 129(3): p. 235-255.

17.       Marion Lee, M., et al., A comprehensive review of opioid-induced hyperalgesia.Pain physician, 2011. 14: p. 145-161.

18.       IASP,Pain Treatment Services. 2009 [cited 2018 20 July]; Available from: http://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1381.

19.       IASP,Desirable Characteristics of National Pain Strategies. 2011 [cited 2018 02 August]; Available from: http://www.iasp-pain.org/Advocacy/Content.aspx?ItemNumber=1473.

20.       Pain Australia, National Pain Strategy. 2010 [cited 2018 21 July]; Available from: http://www.painaustralia.org.au/improving-policy/national-pain-strategy. 

21.       Hogg, M.N., et al., Waiting in pain: a systematic investigation into the provision of persistent pain services in Australia.Medical Journal of Australia, 2012. 196(6): p. 386.

22.       Lynch, M.E., et al., A systematic review of the effect of waiting for treatment for chronic pain.Pain, 2008. 136(1-2): p. 97-116.

23.       Hush, J.M., M. Nicholas, and C.M. Dean, Embedding the IASP pain curriculum into a 3-year pre-licensure physical therapy program: redesigning pain education for future clinicians.Pain reports, 2018. 3(2).

24.       Jones, L.E. and J.M. Hush, Pain education for physiotherapists: is it time for curriculum reform?Journal of physiotherapy, 2011. 57(4): p. 207-208.

25.       Watt-Watson, J., et al., A survey of prelicensure pain curricula in health science faculties in Canadian universities.Pain Research and Management, 2009. 14(6): p. 439-444.

26.       Mezei, L. and B.B. Murinson, Pain education in North American medical schools.The Journal of Pain, 2011. 12(12): p. 1199-1208.

27.       Briggs, E.V., et al., Current pain education within undergraduate medical studies across Europe: Advancing the Provision of Pain Education and Learning (APPEAL) study.BMJ open, 2015. 5(8): p. e006984.

28.       Petrie, K.J., et al., How common are symptoms? Evidence from a New Zealand national telephone survey.BMJ open, 2014. 4(6): p. e005374.

29.       Watt-Watson, J., et al., An integrated undergraduate pain curriculum, based on IASP curricula, for six health science faculties.Pain, 2004. 110(1-2): p. 140-148.

30.       Hunter, J., et al., An interfaculty pain curriculum: lessons learned from six years experience.Pain, 2008. 140(1): p. 74-86.

31.       EFIC,The Pain Management Core Curriculum for European Medical Schools 2013.

32.       DGSS,The Pain Management Core Curriculum for German Medical Schools. 2008.

33.       The National Academies Press, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine. 2011: Washington DC.

34.       Tauben, D.J. and J.D. Loeser, Pain education at the University of Washington School of Medicine.The Journal of Pain, 2013.14(5): p. 431-437.

35.       Doorenbos, A.Z., et al., A blueprint of pain curriculum across prelicensure health sciences programs: one NIH Pain Consortium Center of Excellence in Pain Education (CoEPE) experience.The Journal of Pain, 2013. 14(12): p. 1533-1538.

36.       Fishman, S.M., et al., Core competencies for pain management: results of an interprofessional consensus summit.Pain Medicine, 2013. 14(7): p. 971-981.

37.       IASPIASP Interprofessional Pain Curriculum Outline. 2014.

38.       Breivik, H., et al., Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment.European journal of pain, 2006. 10(4): p. 287-333.

39.       Serbic, D. and T. Pincus, Diagnostic uncertainty and recall bias in chronic low back pain.PAIN®, 2014. 155(8): p. 1540-1546.

40.       Geisser, M.E. and R.S. Roth, Knowledge of and agreement with chronic pain diagnosis: Relation to affective distress, pain beliefs and coping, pain intensity, and disability.Journal of Occupational Rehabilitation, 1998. 8(1): p. 73-88.

41.       Serbic, D., et al., Diagnostic uncertainty, guilt, mood, and disability in back pain.Health Psychology, 2016. 35(1): p. 50.

42.       Grilli, R., C. Ramsay, and S. Minozzi, Mass media interventions: effects on health services utilisation.Cochrane Database Syst Rev, 2002. 1(1).

43.       Holtzman, S., S. Newth, and A. Delongis, The role of social support in coping with daily pain among patients with rheumatoid arthritis.Journal of Health Psychology, 2004. 9(5): p. 677-695.

44.       Buchbinder, R., D. Jolley, and M. Wyatt, Population based intervention to change back pain beliefs and disability: three part evaluation.Bmj, 2001. 322(7301): p. 1516-1520.

45.       Buchbinder, R. and D. Jolley, Population based intervention to change back pain beliefs: three year follow up population survey.Bmj, 2004. 328(7435): p. 321.

46.       Buchbinder, R. and D. Jolley, Effects of a media campaign on back beliefs is sustained 3 years after its cessation.Spine, 2005. 30(11): p. 1323-1330.

47.       Hopfer, S., Effects of a narrative HPV vaccination intervention aimed at reaching college women: A randomized controlled trial.Prevention Science, 2012. 13(2): p. 173-182.