Chronic pain is a complex health issue. While the person suffers the disabling symptoms, its burden extends to the whole of society. In Australia, the burden of musculoskeletal conditions – the most common reason for chronic pain – exceeds that of all other chronic conditions.
The cost of these conditions to the Australian economy in 2012 was more than $A55 billion. Back pain and osteoarthritis, the most common of musculoskeletal conditions, accounted for 52% and 41% of cost respectively.
Pain management is one of the most neglected aspects of health care; our failure to adequately address chronic pain is a major driver of its economic and social burden.
Low back pain and osteoarthritis are among the leading causes of disability worldwide. In 2010, they represented more than 100 million years of productive life lost due to disability.
The Global Burden of Disease Study ranked low back pain higher than any other condition, including major depression, diabetes and heart disease, on this measure.
In Australia, there were an estimated 6.1 million cases of arthritis (26.9% of the population) and other musculoskeletal conditions in 2012. These numbers are expected to rise substantially as the population ages. By 2032, the number of cases is estimated to increase by 43%, to 8.7 million (30.2% of the population).
The $A55 billion cost to the economy can be broken down into direct and indirect costs.
Direct costs are described as the “cost of care”. This includes tests and treatments such as X-rays, medications and physical therapy. Around 17% (more than $A9 billion) of total costs goes directly towards care of musculoskeletal pain.
Indirect costs include lost income, reduced work productivity or participation, and the impact on Gross Domestic Product (GDP). The indirect costs of musculoskeletal pain were around $A20 billion in 2012. More than $A7 billion of these were due to productivity losses alone.
Indirect costs also includes those derived from loss of health or quality of life. For musculoskeletal pain, this cost is a profound $A34 billion per year.
The burden of chronic health is largely a result of its neglect by the health care system. Many patients miss out on critical aspects of care from an early point in their condition.
In 2010, we found that only around 20% of patients with low back pain received the care universally recommended by clinical practice guidelines in Australia and internationally.
The data, which spanned eight years, showed doctors’ consistent failure to provide simple and recommended treatments, such as advice about how to manage pain and reassurance about its nature. Instead, patients were more commonly given inappropriate tests and medications – which are discouraged by guidelines.
As a recent ABC Four Corners program pointed out, overusing such tests and ineffective treatments are a major source of avoidable cost.
Our continued observation that most patients miss out on critical treatment may have a far greater economic impact in indirect costs than is generally understood.
Chronic pain is currently conceptualised within a bio-psychosocial model. This means its experience is influenced by physical, psychological (mood and beliefs) and social (relationships, environment and culture) factors.
Unfortunately, it’s estimated less than 10% of patients with chronic pain receive coordinated multidisciplinary care (involving a team of specialists, which could include a physiotherapist, neurologist and psychologist) to target the multiple drivers of pain.
In our yet-to-be-published research, we found that up to 80% of patients referred for back, neck, hip, knee, or hand pain surgery hadn’t trialled other effective treatments such as multidisciplinary care; or even single modes of care such as exercise or weight loss.
As a consequence, many patients in this category develop multiple risk factors for other chronic disease, such as weight gain and declining activity. These conditions likely contribute much more to the currently recognised social and economic costs.
Addressing the problem
Health policy has long focused on the concept of integrated care – meaning the involvement of multiple health services for comprehensive care of complex chronic conditions. But, in practice, pain has largely been left out of the mix.
Various organisations have advocated for better policy and funding to address the burden of chronic pain. In its National Pain Strategy, Pain Australia recommends better identification of patients at risk of developing chronic pain and providing early access to multidisciplinary care.
Arguably, a more widespread preventive approach would be beneficial. Other organisations have justifiably called for a common risk factor approach to address generic factors associated with chronic pain and other chronic disease. Such factors include being overweight, inactivity, alcohol misuse, poor diet and smoking.
Unfortunately, federal and state governments are yet to adopt a national policy for preventing and dealing with chronic pain. Moreover, the policy landscape remains fragmented by state, region, hospital and health network priorities.
If we are to adopt such a policy, we must also focus efforts on developing strategies to support its local implementation. We have seen time and again the failure of policy alone to make an impact on real health, even when such policy is mandated by government.
For pain, it is no different. Without the crucial step of an implementation plan and importantly, action, the health care system will continue to produce poor patient outcomes with significant economic impact.
This article is part of a series focusing on Pain. Read other articles in the series here.