Time for a rethink in how we approach chronic pain

All of us have experienced brief periods of pain in our lives. But for some people, pain never goes away and comes to dominate their lives.

If you still have pain every day three months after an injury has healed and it is affecting your daily life, the problem has become the pain itself. In this situation, seeking stronger and stronger pain medication will not help and can even make matters worse – as the rise in deaths from prescribed opioids shows.

One in five Australians now lives with chronic pain. This prevalence is expected to increase as Australia’s population ages – by 2050, as many as 5 million of us will likely have severe, disabling pain. Chronic pain impacts people’s ability to work and to perform their daily activities, and often creates a massive emotional burden for pain sufferers and their families. It is estimated to cost Australia more than $34 billion every year.

Chronic pain affects people across the human lifespan, and is more prevalent in older people and lower socio-economic communities. Few people with chronic non-cancer pain gain access to effective care, even though it is likely that most could be successfully helped if they could access these services.

Lack of access to services is especially critical in rural, regional and remote areas and Aboriginal communities. It’s one reason why the number of opioid prescriptions is 10 times higher in some areas of Australia than others. With no other options, people are turning to drugs like Endone and Oxycontin, putting themselves at risk of dependence, addiction and overdose, and still may not experience effective pain control.

But there is a better way. And it requires a radical change in how we think about pain.

We now understand that there are different kinds of pain, and they are processed differently by our nervous system. Pain caused by nerve damage or by the wear and tear of joints that occurs in arthritis are two examples. Some people experience more than one type of pain at the same time.

Most of us imagine pain as a signal to our brain that something is wrong. If we hurt, we take a pill and the pain goes away once the original cause has gone. But that simple formula doesn’t work for all kinds of pain, and chronic pain is not the same as acute self-limiting pain.

Chronic pain is complex, and is often sustained by unhelpful changes in the central nervous system. In other words, the pain results from miscommunication between your nerves and your brain, and between different parts of your brain, not by the triggering injury or illness. It’s more than a symptom of something else; it’s a chronic condition in its own right and influenced by many different factors including the psychological, social and environmental context of the patient.

There is very strong evidence internationally that, to treat chronic pain effectively, all of these different factors must be taken into account.

A study conducted by Sydney University’s Pain Management Research Institute looked at the effect of providing psychological counselling, coupled with workplace support, to people who sustained an injury at work and were identified within days of their injury to be at risk of delayed recovery. Follow-up over the next year showed that those who received this collaborative care were much less likely to suffer chronic pain in the long term and they had significantly fewer days off work than similar cases who received usual care.

Addressing the psychological aspects of their pain and their workplace issues in this collaborative way didn’t just teach them to grin and bear it – it actually helped to limit the impact of their pain and injury.

This is the crux of how chronic pain is best managed.  For many people with chronic disabling pain, a specialist integrated multidisciplinary pain service is recommended. Typically, this can include a combination of (limited) medications along with nutritional advice, exercises, sleep and psychological management strategies tailored to each patient’s needs and goals. But the majority of people with chronic pain can also be helped in the community – especially if they can find providers (for example GPs, physiotherapists and psychologists) to work with them in a collaborative way and help them navigate a way through to the right treatment at the right time.

Unfortunately, in Australia the problem remains that most people can’t access specialist pain services or even appropriate community-based services. That’s why it’s essential that we address pain before it becomes chronic or so severe that it interferes with daily life and sends people desperately searching for relief from unproven, ineffective or harmful treatments. Preventing the progression from acute to chronic pain is a major public health issue of our time.

Health Minister Greg Hunt has just launched a large research project at The Australian Prevention Partnership Centre, funded by one of the first disbursements of the Medical Research Future Fund. This will try to find achievable, sustainable ways to improve pain management in primary care and prevent people from slipping into chronic pain.

Pain is the most common reason that people visit their GP. Given the right resources and support, GPs provide our best chance of identifying people at risk of chronic disabling pain early in their care journey, before the problem becomes established, and those in chronic pain who are not being managed appropriately.

In this project, we will be looking at which care models work and which don’t in different primary care contexts around Australia. We’ll see what GPs need on the ground and what resources different Primary Health Networks might require to implement the strategies we’re suggesting.

Ultimately, our hope is that much of the burden of chronic pain can be averted with simple strategies that don’t rely on opioid medications. Intervening early and providing people with evidence-based treatment could halve the economic costs of chronic pain, and go some way to ending the risk of opioid tolerance and addiction.

For the millions of Australians at risk of chronic pain, it will give access to the basic right of all people to good pain management and minimise their risk of a life of disability, opioid dependence, and social isolation.

Fiona Blyth AM is Professor of Public Health and Pain Medicine at the University of Sydney and Head of the Concord Hospital Clinical School in Sydney Local Health District, and an Adviser for Pain Australia, the Pain Management and Research Institute and the Sax Institute. She is leading a new research project at The Australian Prevention Partnership Centre, ‘Strategies and models for preventing or reducing the risk of the development of chronic pain in primary care.’

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