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Pain medicine: an important speciality you might not have heard of

Imagine being so debilitated by persistent pain that it impaired your ability to work, causing income stress or forcing you into early retirement.

The recent Productivity Commission report highlighted that this is the case for many Australians. The Commission reported that one in five Australians live with chronic pain and it accounts for 40% of early forced retirements in people of working age.

Importantly, they estimated that half of the estimated $11.7 billion foregone due to lost productivity could be saved by providing effective and timely treatment.

More important is the human suffering that could be avoided with such treatment.

What does effective treatment of chronic pain look like? In the post below, pain specialist, and board member of Painaustralia, Dr Malcolm Hogg, writes about the challenging and ever-evolving discipline of pain medicine.

The waiting times to see pain specialists or attend multidisciplinary clinics can be long, and reducing this time, along with general upskilling of health professionals, will be needed to mitigate the personal and financial toll of persistent pain.

To this effect, the RACGP launched a ‘Part C’ to its guidelines for prescribing drugs of dependence in general practice at its annual conference yesterday. Entitled Opioid prescribing, the guide provides practical advice for the management of both acute and chronic pain, as well as a ‘Twelve Point Challenge’ for optimal pain management practice.

In other news this morning, Federal Minister for Health, Greg Hunt, has announced that the government will provide $1 million in funding to ensure health practitioners and consumers are informed about upcoming changes to accessing codeine-containing medicines. As previously detailed at Croakey the move to make codeine-containing medications prescription-only from February next year, while endorsed by medical, consumer and pain advocacy groups, has not been welcomed by the Pharmacy Guild of Australia.

Minister Hunt said the government would provide funding to peak GP and specialist groups, including the Royal Australian College of General Practitioners, the Royal Australasian College of Physicians, the Rural Doctors Association of Australia, the Australian College of Rural and Remote Medicine and the Australian Medical Association. It would also allocate funds to the provision of public information via the Pharmacy Guild of Australia and the Pharmaceutical Society of Australia, and to Painaustralia, supported by the Consumers Health Forum, to develop and implement dedicated pain management strategies.


Dr Malcolm Hogg writes:

Millions of Australians will experience chronic pain, often referred to as persistent pain, the vast majority of whom will never see a pain specialist.  Many people are unaware that such a medical speciality exists.  This is despite the fact that chronic pain is a major national health issue.

The burden of persistent pain

The burden of disease associated with chronic pain – constant daily or recurrent pain – is estimated to cost over $34 billion annually, is the leading cause of forced retirement, is one of the major contributors to the burden of disability in Australia, and is third only to cardiovascular disease and musculoskeletal conditions among National Health Priority Areas (chronic pain itself is not a priority area).

We are talking about a condition that affects around 20% of Australians, with an impact comparable to heart disease and cancer. The persistent pain experience is complex and, while not yet fully understood, involves social, psychological and biological factors contributing to a change to the nervous system and body as a whole; many researchers and clinicians view chronic pain as a disease in its own right due to this multi-dimensional impact on an individual.

It is not difficult to see why chronic pain is commonly poorly managed – either by using an approach consistent with acute or short-term pain, which focuses on analgesia but is largely ineffective for chronic pain; by assuming it is a symptom of some other condition and ordering multiple yet inconclusive diagnostic investigations; or by dismissing it into the ‘too hard’ basket or worse, the ‘all in your head’ basket.

There are some important patterns associated with chronic pain, but it is also very much an individual experience.  Chronic pain is not like a broken bone, a tumour, an infection, where various scans and tests will identify the issue, and clinical knowledge will inform the appropriate treatment response, leading to repair or cure.

Pain management specialists

By the time people are referred to a pain specialist or a pain management clinic, in most cases their pain will have already taken a significant toll.  Chronic pain can impact brain function, movement, mood, sleep, relationships, work, and day-to-day capacity to live.  People experiencing chronic pain will often lose hope and trust in the health system.

Advocacy body Painaustralia and its members and stakeholders are working to change this: reduced wait times and better access to public pain management services; a health workforce that is appropriately educated in best-practice pain management techniques; education for consumers in self-management of chronic pain; and more affordable allied health.

Commonly the goal of chronic pain management is not to reduce the pain levels per se, but rather to help the person live and function better with pain, such that they can lead more fulfilling and productive lives.  Interestingly, pain reduction may follow these improvements, reflecting the ongoing flexibility and adaptation of the nervous system, specifically the brain, the organ where ultimately pain is experienced.

The first role of a pain specialist is not to offer quick fix solutions, but to listen, commonly scheduling an hour for initial consultation or assessing over several sessions, often including the support of other clinicians.  What we often hear is anger, frustration, disappointment.  When we ask what the patient believes would be a good treatment outcome, most talk about wanting their lives back.

Prior to seeing a pain specialist, most patients will have consumed a range of analgesics, often at high doses with potentially serious side effects, including drug dependence.  Most will initially oppose further treatments due to their experiences of treatment failures.

 A multidisciplinary approach

Best practice pain management involves working with a team of knowledgeable and experienced clinicians.  Pain has a psycho-social dimension, which reflects the complex neurology of pain; i.e. the contribution to and subsequent impact of pain on mood, sleep, thinking and distress has a neurological basis.

Treating someone with chronic pain is little like trying to solve a three-dimensional puzzle.  Input from other specialists with different perspectives is critical to ensuring we not only have a complete picture of what is happening, but also that we consider a range of possible interventions.

A pain specialist will typically call on the expertise of a physiotherapist, psychologist, occupational therapist, social worker, and/or a nurse; we work as a team in order to provide the multidisciplinary approach a person with chronic pain requires.

We may arrange imaging like MRIs, nerve conduction tests or perform in-depth psychological assessments to ascertain both the structural and psycho-social contributors to the pain experience.  Identifying and addressing these factors is usually a key intervention in optimally managing a person suffering chronic pain.

Medication, particularly opioid-based, is not considered effective for the treatment of many people with chronic pain and opioids have a limited role in a multidisciplinary approach.  In the end, most people find they can self-manage their pain condition with less reliance on medication.

Partnering with patients

Working with the individual to minimise their suffering and maximise their function can be rewarding for all involved and can significantly reduce the costs to society.  We are commonly called upon to advocate for care plans within workers’ compensation, transport accident and legal systems. Good clinical outcomes will be beneficial for all concerned.

One of the most difficult aspects of my role as a pain specialist is convincing patients that I and our team have knowledge and expertise that will help them address their pain.  Many of my patients are treatment resistant (but may be reliant), despondent and disabled, understandable given their often arduous journey.  The treatment solutions they are commonly offered like analgesics and surgery are often not effective and may contribute to worsening levels of pain and distress. 

A challenging specialty

Pain specialists do not have a high positive profile, like colleagues treating cancer or heart disease, yet we enjoy the challenge, the team approach and seeing the benefits of helping a diverse group of people with significant suffering and disability. The field of pain medicine is complex, constantly developing and debating optimal assessment and management approaches.

We hope to see further developments to assist those suffering pain, in both medical and psycho-social domains; part of the development we aspire if for greater recognition by communities, health care systems and governments in the importance and great benefit in offering optimal pain management to persons in pain.

*Malcolm Hogg is a specialist in Anaesthesia and Pain Medicine and Clinical Associate Professor, University of Melbourne.  He has over 20 years experience in providing care for those with pain and is currently employed as Head of Pain Services, at Royal Melbourne Hospital.  Dr Hogg is a Past President of the Australian Pain Society and current board member of Painaustralia, a not-for profit advocacy body.