Unrelieved pain: a major health care priority

Pain in patients has long been underestimated, and sufferers poorly served and stigmatised by previous health care approaches which have lagged behind the advances and recommendations of the time. Undertreatment of acute pain in Australia has been discussed over the past 24 years in editorials1 and guidelines,2 as have proposals for improved treatment.2,3

Cancer pain is in a similar situation to that of acute pain, with 50% of adults4 and children5 being undertreated, despite effective treatment being possible for most patients. Patients with chronic non-cancer pain face a worse situation; they are frequently stigmatised,6,7 and a large majority do not gain “access to appropriate assessment and treatment of the pain by adequately trained health care professionals”.8

Absences of data on the prevalence of pain and the associated costs of treatment have conspired to make pain almost invisible as a national health priority. But epidemiological studies by Blyth and colleagues revealed that chronic pain has a prevalence in Australia of close to one in five,9,10 similar to the prevalence in the United States.7

However, a more comprehensive view of pain has finally emerged to address these problems. In Australia, a draft National Pain Strategy (NPS) was prepared with input from health care and consumer organisations, and finalised by more than 130 health care organisations, including medical colleges, consumer groups, insurers and work safety organisations, at the National Pain Summit in March 2010. The resulting NPS (http://www.painaustralia.org.au/the-national-pain-strategy/national-pain-strategy.html) is the first worldwide pain plan with goals and strategies to address inadequacies in pain management. In response to the NPS, the Queensland Government allocated $39 million to a Statewide Persistent Pain Health Services Strategy, the Western Australian Government developed a Spinal Pain Model of Care (and supported the formation of Painaustralia), and the New South Wales government indicated it would introduce a statewide pain management program.

A key idea identified is the “underlying principle of chronic pain as a disease in itself”.7 This concept was initially proposed in 2004,11 based on evidence of nervous system changes in people with chronic pain, and of pain-related psychological and environmental changes. Brain imaging studies suggest structural and functional changes which are reversible if appropriate treatment can be applied.12

The International Pain Summit (IPS) (http://www.iasp-pain.org/Content/NavigationMenu/Advocacy/InternationalPainSummit/default.htm) developed a broad framework suitable for use by any country (http://www.iasp-pain.org/PainSummit/DesirableCharacteristics_Nov 2011.pdf). Perhaps the most important outcome of the IPS was the Declaration of Montréal on pain management.6 The 2011 council of the World Medical Association resolved that “people facing pain have a right to appropriate pain management” (http://www.wma.net/en/30publications/10 policies/p2). Also in 2011, the European chapters of the International Association for the Study of Pain developed a transnational document on the impact of pain (http://www.efic.org/index.asp?sub=YMQ39bfQ m3D8IA).

Chronic pain is no longer relegated to the background, but is now considered a clinical entity in its own right, requiring specialised, multifaceted care that brings real improvements to patient wellbeing. But there is still some way to go before the Australian health system can deliver such improvements. The Australian NPS details the barriers to improved treatment in the current model of care. A multidisciplinary pain management network is proposed, with emphasis on the primary care level, but also on community care for information, education, self-help, and support. The NPS provides goals and 120 strategic actions, which include:

• • destigmatisation of people with pain

  • education for all health professionals on treating chronic pain as a chronic disease

• adequate management of acute pain to minimise the risk of it progressing to chronic pain

• a monitoring system (now introduced) for opioid prescriptions to reduce the risk of inappropriate use.

These recommendations show that, in both acute and chronic pain, change is necessary, but also achievable, to deliver the best possible care.