Addressing chronic pain – one of our biggest health problems in Australia

Gretchen Miller: Hello once more, and welcome to Prevention Works, the podcast of The Australian Prevention Partnership Centre, where we talk to some of Australia’s best researchers and investigators into Australia’s problem with lifestyle-related chronic disease. I’m your host, Gretchen Miller. And today, another big topic. Something I think I can safely say, none of us will escape a brush with, and that’s pain. Whether it’s a temporary injury, or ongoing chronic pain, pain is part of being human.

According to Pain Australia, peak organisation for pain sufferers, carers and family, we have an epidemic of it. One in five Australians live with chronic pain. A fifth of our GP consultations involve a patient with chronic pain. And 10% of us report severe, disabling chronic pain. As the nation ages, the pain incidence will only increase, with one in three people over the age of 65 suffering.

Fiona Blyth: It may be that the goal is not to completely eliminate the pain. But it’s a combination of reducing pain and increasing functionality. So, we often hear this term pain relief, and the concept of pain relief as a human right. I certainly think good pain assessment and good pain treatment is a fundamental human right. But the ways in which people get relief from pain can vary. And for a lot of people, they can live long, good, happy lives without perhaps pursuing the ultimate goal of having no pain at all.

Gretchen Miller: There’s evidence that 80% of people with chronic, non-cancer pain could be treated effectively, if they could access appropriate services, an extraordinary figure. So, Prevention Works is today visiting Concord Repatriation General Hospital in Sydney to meet with Fiona Blyth, Head of the Concord Clinical School, and Professor of Public Health & Pain Medicine at the University of Sydney.

Fiona is leading a pain research study with the Prevention Centre. We begin with that new understanding of chronic pain, a story I observed firsthand in a friend who 10 years ago hurt her foot while dancing. She rested it on her GP’s advice, and it became months and years of terrible, immobilising pain … even though the original injury had healed. The pain had become the disease.

Fiona Blyth: This is a story that needs to be told. It’s a story of, if you like, the focus still being on what the triggering event was. And the slowness of the medical system in your friend’s case, to just step back and say, “Well, what’s the main problem, now?”

Gretchen Miller: Apparently, it was those days of rest, which really messed it up. She should not have rested it. She should have kept using it.

Fiona Blyth: That could certainly happen. We certainly have come to understand that over-reliance on rest is actually harmful. So unfortunately, there’s a legacy of that we’re still dealing with today. And then, I think the problem is, of course, pursuing, if you like, the acute trigger for too long … means that the focus is taken away for how the problem is evolving. And also, we have to understand that a lot of the tests that are commonly used are really just not that useful.

Gretchen Miller: Such as what tests?

Fiona Blyth: Well, X-rays and MRIs. Unless you have a very specific reason to be doing them to rule in or rule out a very particular diagnosis, for which you know X-rays or MRIs or other forms of imaging, are very useful…

Gretchen Miller: Like cancer, for example.

Fiona Blyth: … Yes. But if you don’t have a very good reason for ordering a test, then you run the risk that the tests will show something up, but its significance is unclear. And it may be an incidental finding. Certainly, if you did an MRI of anyone’s back, anyone’s lumbar spine, who’s aged over 40, then you will find something. And then the question is, “Is it significant? Is it related to the problem that the patient is having?” This is a huge problem, still, in primary care … is the over-ordering of tests. The finding of things that are actually incidental to the problem, and the pursuit of these, while the real problem remains undealt with.

Gretchen Miller: And there’s a critical time window, in which you have to catch the original source of the pain, isn’t there? So, while you’re distracted with all the other stuff, that window is closing.

Fiona Blyth: So normally, if someone has an injury you would expect the acute phase of pain and reaction to settle within a short number of weeks. If it doesn’t, but you’re still pursuing the cause, but not noticing that actually, the problem of the pain itself is becoming more centre-stage, and other features around it like avoidance of use, is really becoming a prominent feature, then what’s happening is that these changes that we know happen in the brain with that ongoing stimulus, are starting to get more set in their ways.

Fiona Blyth: So, these characteristic changes that we call central sensitisation, start to become more pronounced. The inability to damp down the pain signals that are coming in, all become more entrenched. And also, the secondary problems that come … we’ve talked about rest, the deconditioning actually happens really quite quickly.

Gretchen Miller: So what you’re saying is that the brain creates pathways to tell you that you have pain, even when the original injury has gone away and that happens quite quickly?

Fiona Blyth: Well, the pathways are there. They’re there, anyway. But it’s just that the signalling keeps coming in. But after a while, the problem isn’t so much the signal from the original site, or the ankle or the hand, it’s what’s happening centrally in the brain, becomes the dominant characteristic, or the main thing that is the problem there. And it’s recognising those people who perhaps are most at risk of this, is really the key thing.

Gretchen Miller: So it sort of sounds still a little bit frightening, in that we don’t quite know why it happens. How far off are we from understanding, say, the story of my friend, and finding a solution?

Fiona Blyth: I think the science is so rapidly evolving in this area. There have just been such insights over the last 20 to 30 years. And of course, with the advent of things like functional imaging of the brain we start to understand quite how the brain processes. So, this concept that there’s not just one pain centre in the brain, but a whole range of different areas that are involved in pain processing and evaluating pain, is really a major step forward. It’s true there’s a long way to go, but I think even the ability to show patients that …

There’s this pejorative expression of, “It’s just all in your head.” Well, yes. It literally is all in your head; the pain processing is in your head. And I think that is really important, that patients are given, if you like, that validation that something that is a large source of suffering, but is entirely invisible to the rest of the world, has a signature in the brain.

Gretchen Miller: So, can I ask if, say, you have a bad back, and you have a chronically bad back, is that what we’re talking about? That the original source of the pain is gone, but the pain in your back remains?

Fiona Blyth: That is right. In many, many cases of back pain, the underlying trigger is really not apparent. So we have to think what happens over time? You get changes in the way your brain processes pain, and one of the characteristics of that, is that we all normally have a way that our brain dampens down the effect of the signal of pain that comes in. That ability to damp down, is very often reduced in people who have chronic pain. We also think, what do people with, say, long-term back pain, do?

They become more cautious, physically, reduce their activities, become more guarded in what they do. And that then creates secondary problems around stiffness, muscle weakness, posture problems and then that can often affect joints further up and down the back. And then, of course, people evaluate pain. It has an effect on them. It’s not just that it is burning or throbbing. It’s also, is it tiring, is it worrying. Is it troublesome? And do people start becoming avoidant and fearful, because of their pain?

So really, once those things start coming in, or they start having problems with sleep, then really, you’ve got to unpick what are the main drivers there. And what are the most effective ways of intervening on them. And it might be different from one person in a pain program to the one sitting next to them. That’s why it’s really important to do a thorough person-based assessment. Because it’s also around, what’s that person’s goals? What is it that their chronic pain is stopping them from doing? Because people will be motivated to get back to things that give their life importance and meaning.

That’s really what the treatment should focus on. Also, when we talk about chronic pain, we’re talking about something that is not just about the intensity that people experience. It’s around the psychological components of pain, the social components of pain. And there would be no medication on the face of the earth that I could think of, that would adequately deal with all of those things. Which is why, when we have highly problematic complex patients, a multidisciplinary approach is really the recommended one.

Gretchen Miller: So there’s a bit of psychology in there, as well. So, reminding them of their goals as a motivator for doing, say, exercise or attending physio. What about the kinds of pain that you get when, say, your cartilage is worn away – and so the source of the pain doesn’t go?

Fiona Blyth: Well, there again, you’d first of all see, well, is there something in the … say it’s the knee cartilage. Is there something there that can be done locally? But then it’s the same questions. What’s the impact it’s having on you? Is it affecting your sleep? Have you got deconditioning? Are you running into side effects with your medications? So really, the same bundle of things tend to occur because we know that certain things happen very commonly when people are troubled by pain. And we also know that, in terms of the way that pain is processed by the brain, it’s a distributed thing in the brain so it shares brain circuitry with many things, like mood, fear. That’s why we see these things in a typical constellation when someone has persistent pain that is troubling them. Because the overlaps in brain circuitry are very well-known.

Gretchen Miller: So in the context of chronic pain, do we have a problem with the overuse of opiates as a treatment for pain?

Fiona Blyth: Well, it’s certainly true in general, that if you look at data from general practice, if someone presents with a pain problem, the most likely thing that happens is that they’ll get a prescription. And we know from a lot of evidence overseas, particularly from America, that there has been a problem with over-reliance on long-term use of opioids to manage chronic pain.

Gretchen Miller: As I understand it, they’re actually only very useful at the beginning of pain. They’re not useful for chronic pain. Now, that surprises me. Can you explain that?

Fiona Blyth: It’s true that opioids are a mainstay of treatment of acute pain. We think of pain after surgery. The reasons why opioids are not useful in chronic pain, are only really becoming well understood as we unpick our understanding of the underlying neurobiology of brains, and –

Gretchen Miller: So, they actually stop being efficient. They stop taking away the pain?

Fiona Blyth: They do. Because all of us have our own internal, what we call, endogenous opioid systems that are actually very important in the day-to-day regulation of how we experience pain and anticipate pain, and damp it down. If you give people high doses of opioid medications for long-term, it completely suppresses that system. And that is one of the major drivers of why it becomes problematic in the longer term.

Gretchen Miller: So, if you are a person with pain, listening to this, I think you’d be quite curious as to the alternatives to opioids. What do we have? Do we have different drugs? Do we have physio? Psychology? Can you go into a little detail on those?

Fiona Blyth: Well, you’re right. There’s a range of things we can do. There are a range of medications and they have different purposes, and different strengths and weaknesses. That’s why it’s really important for a good assessment that tries to say, “Well, what do we think is the underlying mechanism? Is there a triggering cause that’s still promoting this problem, that we can remove?” Although, by the time someone’s had pain for three or six months or more, often that trigger is no longer there. But because of the changes in the way the brain processes pain, it has become a self-sustaining phenomenon which needs attention to its components, not just whatever started it in the first place.

Gretchen Miller: People who are affected with pain in their day-to-day lives … what levels of pain are we talking about?

Fiona Blyth: It’s really variable. We know that there are some people in the community who might report quite high levels of pain, but maintain quite good levels of function. However, we know there are many people whose lives are seriously limited by pain. They become distressed, they become less active, less able to participate in things that give their life meaning, like work, caring for other people, and socialising. So, it’s really variable. And even for one person, it can vary over time.

Gretchen Miller: I read a description of pain, which was, that it was so bad, they couldn’t even stand the brush of a feather on their skin.

Fiona Blyth: That is a very common feature of neuropathic pain conditions. It represents, if you like, the nervous system not responding to pain in the correct way. And those sorts of sensations are very troubling, and also very hard for a person experiencing it, to understand. Pain is a very individual experience. However, we know that there are common drivers of it. This is the pain we might expect to feel if we stub our toe, which in a sense, you might say is in some ways, a useful pain. Because it warns us of danger, and we call that nociceptive pain. But we can also talk about the types of pain that happen from nerve damage. And one common example of this is shingles, which is a very painful complication of infection. And trigeminal neuralgia is another of those types of pain.

Gretchen Miller: How would you describe that pain?

Fiona Blyth: What’s characteristic about this group of pains that we call neuropathic pains, is that they have a particularly unpleasant quality to them. They also have some unusual features, so that they can occur when people are at rest, and they can occur spontaneously and unpredictably. It’s the unpredictability that people find very difficult to manage.

Gretchen Miller: I’m interested in whether different countries handle pain in different ways. And I’m wondering why it is an increasing issue for Australians.

Fiona Blyth: It’s an interesting question. I think, although we do understand that pain always occurs in a social context, and that social context has to do with culture and beliefs. But it also got to do with much more concrete things, like resources that are available. I think in Australia what we see, is a combination of better understanding, not just amongst health professionals, but also amongst the community.

I think that chronic pain and pain is something no one ever talked about in the past. It’s invisible. There weren’t many treatments available. There’s no magic painometer test that goes “bing” when someone’s got pain. And I think, for all those reasons, and I think also, a stigma attached to having pain. And for all those reasons, and the lack of good data telling us, “This is a common problem. This is the size of it. This is what it looks and feels like in Australia.”

Gretchen Miller: I’m now wondering whether the Australian, “She’ll be right, mate” is actually a cultural disability, when it comes to expression of, and admitting to having, pain.

Fiona Blyth: I think that is an issue. And I think it’s a two-way street. Patients with pain may not like to raise it with their doctors. And the doctors and other health care professionals may not want to ask about it. That may be for very, sort of, concrete reasons. Particularly in older people, where pain will not be the only problem that they have. And in the context of a highly-pressured primary care consultation, it simply may not be high enough up the list of things to get discussed.

Gretchen Miller: What is really fascinating to me is that we can actually vastly reduce the statistics of Australians suffering pain. We actually have the know-how. What could be done, and by what proportion, could we reduce our experience of pain, as a nation?

Fiona Blyth: There is no doubt that a large proportion of the burden that we see, can be reduced right down. And we can think of it in a number of ways. We’ve obviously got the current burden that we’ve got for people who’ve had pain in the community for a long time. We are getting much better at matching patients to treatments. There’s also the issue of how do we prevent it happening in the first place. Now obviously, as a species, the ability to experience pain and things that are dangerous, is really important.

But how can we get better at saying, “Well, this person’s had acute pain for a while, but maybe it’s going on for a bit too long. Maybe they’re getting very distressed by it.” It’s around really being able to work out who is most at risk, and what to do with them … I think, will help us prevent it in the future. But I think, when we also think about reducing the burden, we think, “What’s the goal, here?”

So, for someone with chronic pain, it may be that the goal is not to completely eliminate the pain. But it’s a combination of reducing pain and increasing functionality. So, we often hear this term, pain relief, and the concept of pain relief as a human right. And I certainly think good pain assessment and good pain treatment is a fundamental human right. But the ways in which people get relief from pain can vary. And for a lot of people, they can live long, good, happy lives without perhaps pursuing the ultimate goal of having no pain at all.

Gretchen Miller: You’re with Prevention Works, from The Australian Prevention Partnership Centre. Coming up, we’ll be talking about just what we can do outside of specialist services, to improve pain management. And just a little request: If you like us, leave us a review on iTunes, as it helps others to find us. And also, the podcast is now on Spotify. So, bad backs are a common and lasting pain problem. What’s the solution, if you’ve had one for 30 years? And where can health professionals go to prevent a new generation suffering longstanding back pain?

Fiona Blyth: Well, we know that when you have a multidisciplinary approach, that looks at all the things that have really come out of that experience of pain that are affecting peoples’ lives, and you act on those to make people upgrade their exercise … We want to avoid this concept of the boom and bust. So, someone goes hammer and tongs when they can, but then they spend the next three days in bed, is not a good way to live in the world.

It’s around, how do you give people confidence to pace themselves out, get good at a certain level of activity, and then raise it up to the next level? How do they deal when there’s a setback? And how do they reflect on how they’re thinking about their pain, how it’s affecting their behaviour, giving them new strategies to do. It’s not just something that you think sounds about right, it actually does help their brains modulate their pain.

If you like, it can help damp down some of the problems that have occurred as a result of this pain persisting for some time. So, the brain is a remarkable organ. Even after people have had chronic pain for a number of years, if they’re given treatments that really … not just going for one target in the chronic pain spectrum, but actually systematically attacking different parts of the problem, then the positive neuro-adaptation of the brain kicks in. This is a good news story.

Gretchen Miller: The thing is, though, is that the problem is so large and so common. We might never be able to deal with it through specialist services. So, what does that mean the general health system needs to come to grips with, to improve the experience of Australians’ lives in this respect?

Fiona Blyth: It is around a range of things we need to do. It’s around matching up the right patients with the right treatments. It’s also around training and capacity-building in communities, with health professionals. And I think also too, we really have to see it as a partnership, if you like, between the community and the health system. You are completely correct in that it’s not appropriate to think for the nature and the size of the problem, that the answer is to provide more specialist services.

They’re very important for the people who need them most. The other side of this, of course, is that many, many people, if they are assessed well, or present early, and have a really accurate and thorough assessment of their pain, can have very good outcomes. And they don’t involve having to go to a specialist pain clinic. And it comes back to this concept of matching the right patients with the right treatments. And I think it’s really around who are the ones that we think might be at high risk of very poor outcomes, referring them on early.

The flip side of this, of course, is discouraging the use of treatments that are invasive, and may have no really good scientific basis. Because we see that, as well. Reducing ineffective care, increasing effective care but also, helping our patients navigate what’s a very complicated system. There are many things out there that purport to help people with pain. But how does a patient, a consumer, sitting in the middle of this, wanting help with their pain, how do they navigate that system?

Gretchen Miller: What are you doing with the Prevention Centre, in terms of this research? Where is this research going to take you, and what are you looking at?

Fiona Blyth: Well really, the heart of this project is around what’s happening in primary health network spaces that is addressing this problem of chronic pain, both in terms of managing people in the community who already have it, but also hopefully, trying to address it early, before it becomes a fully blown problem. This project has two phases. First of all, is finding out current activity all around Australia. Not just in metropolitan primary health networks, but importantly, out in regional areas as well, and in different types of populations.

Seeing whether things that are being done are being evaluated, mapping it to the best evidence we have about these sorts of interventions, and then also helping PHNs work out how they can tailor their own strategies around chronic pain, based on things that have been proven to work in Australia, in other PHNs. But also, what the evidence might be telling us might be useful.

Gretchen Miller: So, it’s both a discovery exercise for you, but also, a means to educate at the same time. That’s very particularly special kind of research, isn’t it?

Fiona Blyth: Yeah. No, that’s exactly right. And I think what’s been obvious to the research team, myself-included, since we started this, is how diverse the primary health networks space is. They really are a very diverse community of organisations. Which is not surprising, given their locations, and the populations that they serve. And I think understanding that diversity and the drivers, and capacity of each PHN, to deliver services, or access services, has been a really big learning for us.

But also, expands the scope of what we think might be useful in that space. Whether it might be supporting more community-based pain self-management programs. It might be training of health professionals, it might be developing care navigation tools to help patients find their way through existing services. It turns out it’s a very diverse and vibrant landscape out there. Certainly, it’s been very interesting, even in the time we’ve been going to understand that.

Gretchen Miller: So in that context, and in the growing understanding of pain being a disease in its own right, that is really significant. What are the implications therefore, for further research into pain, now that that acknowledgement has been made?

Fiona Blyth: I think the implications are really huge, because it means we are accepting the proposition that it is a disease in its own right. And in fact, later on this year we hope we will see for the first time, the adoption of specific primary pain codes within our internationally accepted way that we code diseases when people turn up and are admitted to hospitals.

So in a way, part of the problem has been that although those of us who work in the field, know and recognise it to be a problem in its own right. Having the numbers and the data has been a much harder thing to do. So, once we get these codes being used regularly, when people are admitted to hospital, it then gives us a very powerful tool for saying, “Look, this is really a big problem in your hospital, or your area. What are you going to do about it?”

Gretchen Miller: So, codes are kind of implicit, formal, official recognition of particular kinds of pain?

Fiona Blyth: Yes. I think also too, the way that resources get allocated by health departments and research bodies. One of the big drivers of it is an understanding of how big a problem is this health problem in the community. That’s why we see things like cardiovascular disease, cancer, mental health being well known as areas where efforts are put by health systems and by research-funding bodies. But although we have a very good understanding now of how big, globally, the burden of pain is, we haven’t yet had that cut through for it to be recognised as such.

Fiona Blyth: And I think as much as we need ongoing research into the underlying mechanisms for pain, better medications, better treatments for pain based on our understanding of how pain works in the body. We also need good research in how to cut through to governments and funders to say, as much as cardiovascular disease is a priority area, as much as mental health is, more recently, a priority area … pain needs to be one, as well.

Gretchen Miller: What a great place to leave it there. Professor Fiona Blyth, thank you so much for joining us on Prevention Works. There’s more information on our website  And check out all the other ways the Prevention Centre is tackling chronic disease. Lots of other conversations about new Australian research there. I’m Gretchen Miller, and I’ll see you next time.