The MJA this month leads a themed edition with an editorial on the public health and social consequences of persistent pain which makes sobering reading. For my own part I am well aware of this, as I spend most of my working life (when I’m not pinching the time to write these columns of course) working with sufferers of various types of pain.
There are many barriers to adequate treatment for pain-related problems, and it is an area of medicine where Australia spends shamefully little on research. In the UK, Europe and the US there are many basic science labs researching pain-causing conditions. There are clinical research institutes and academic departments of pain management. In Australia….tumbleweeds. A few committed and charismatic individuals have been able to convince the universities and governments to fund their research, but there is no co-ordinated national framework to even begin addressing the problem. The Pain Management Unit where I am based, which was the first in Victoria, did not have a secure long-term funding stream until last year. That meant for more than a decade we were solely dependent on the goodwill of the CEO and executive of the organisation as we raided the budget of our parent department on an essentially ad hoc basis. According to the Australian Institute of Health and Wellbeing’s 2005 figures, musculoskeletal pain constituted the single largest disease non-fatal burden in adults. It is a public health and economic problem that is rivalled only by mental health and cardiovascular disease when you look at the disability it causes. It’s hard to believe that so little has been seriously done at a government level to address it.
As difficult as it has been for us to get our service funded, it has been even harder for those we serve. First-line nerve pain drugs like gabapentin, pregabalin, duloxetine and amitriptyline are not on the PBS for this indication. Pregabalin is not even on the PBS at all. One of the cornerstones of drug management of pain is the opioid class, which is subject to so much social repugnance and misinformation that many choose not to even try them. Others may be forced onto them because more effective and less potentially harmful treatments are denied them by geography or lack of infrastructure, due to decades of underinvestment in pain services. Poorly treated pain sufferers are probably second only to cancer patients in their vulnerability to outright quackery for these reasons as well. Serious pain management expertise can improve the lot of most of those who manage to get to see someone, but this expertise is only available to relatively few. In the absence of something more effective, desperate people turn to improbable measures.
Australia is a wealthy, first-world society with a strong economy and an identity built on helping others through adversity. The underbelly of this identity can be a suspicion and scapegoating of those not perceived to be pulling their weight. If I was trying to fake my way onto a pension, I would certainly not pretend to be a chronic pain sufferer. If you look at the figures it’s not a lifestyle you would choose at all.