September 26, 2020

CP Online Health

Eat Well, Life Well

Chronic/persistent pain management is not sexy. No-one gets a magic cure. Lives are not saved – at least not in a way that mortality statistics show. Chronic pain management is under-funded.

And now: buried in a list of other proposed service cuts in the local health board’s plan to save millions of dollars, is a proposal to “save” $650,000 from the pain clinic. You’ll note also reductions in community services, GP support for vulnerable, and healthy lifestyles programmes.

https://www.stuff.co.nz/national/health/122558278/hundreds-of-staff-nurses-and-services-may-be-axed-at-canterbury-dhb

I know that nursing staff, senior medical staff and 200 admin staff are also in the firing line. I also know that this health board has been side-swiped by earthquake earthquake re-building, the terror attacks with so many victims needing urgent and ongoing surgery and rehabilitation, along with the mental health impacts of all of these events and now Covid-19… Delays and poor workmanship on new buildings on the main hospital site have meant these new facilities are well over-budget, and two years late – and there is still no car-parking for patients and staff. Historic under-funding by past governments has meant Canterbury DHB has developed innovative and nimble responses to these challenges – and been lauded internationally for their work. I won’t say anything about the growth in middle management, suffice to say that where there was once one general manager at one site, and a direct report line from the clinical director of a service – now there are three or four layers of management…

Let me turn to why cutting expenditure on pain services is likely to cost rather than save.

In 1987 or so, a new pain management service was developed in Christchurch. One of the primary reasons for opening this centre was to address the burgeoning rise in numbers of people presenting for orthopaedic surgery but for whom surgery was not an option. Either because there was nothing to find on imaging – pain can’t be imaged, and surgeons can’t operate on a normal x-ray or MRI – or because the person’s problem would likely not respond to surgery.

As a result of the new pain management service, people who weren’t suitable for orthopaedic surgery were referred for multidisciplinary pain management: medical assessment, functional assessment, psychosocial assessment, and appropriate pain management from there. Fewer people with low back pain were being admitted to the orthopaedic wards as a result. Win!

It’s only possible in the first few years of a service to clearly demonstrate the impact of it on the rest of the health system. Why? Because it’s not possible to show what isn’t happening. Now that pain management services have been in place for many years, the effect of people attending these services rather than other parts of the healthcare system is invisible.

For example, people who attend pain management services don’t need as many ambulance trips, visits to the Emergency Department, admissions via Emergency to hospital wards. They don’t stay in hospital beds while they undergo investigations – all the while using bed space, “hotel services” (food, linen, soap, towels, hot water, cleaning services), along with the skilled healthcare staff – doctors, nurses, physiotherapists, occupational therapists, laboratory workers, phlebotomists, radiographers, pharmacists and on and on…

People who are served well through pain services don’t take up as much space in the rest of the system – and the very people who need pain services are the people who otherwise do end up in many places throughout the healthcare system (Blyth, March, Brnabic, Cousins, 2004; Duenas, Ojeda, Salazar, Mico & Failde, 2016). It’s evident from so many epidemiological studies that people with chronic pain will have an impact across “physical” health services, “mental” health services, primary care (General practice), secondary care and tertiary care. And an acute hospital setting is not the right place for people with chronic pain to be treated.

Until recently, though, admissions for chronic pain haven’t been counted as “chronic pain” because the coding used (ICD10) doesn’t have chronic pain as a stand-alone category. This means a person with chronic abdominal pain, for example, will have their condition listed within an acute pain admission category. Similarly with chronic non-cardiac chest pain – these admissions are coded as “cardiac”. The new ICD11 will help make these currently hidden admissions visible – but currently, it’s not possible to identify just how many people are being seen in these departments but who could be better managed in a persistent pain clinic.

Now I’m the first to admit that our treatments for chronic pain don’t show massive effects. Pain intensity, disability, distress all continue to have an impact on people even after attending a pain service. BUT that is the nature of a persistent pain problem – people don’t die from it, but like those with “long-Covid19”, they continue to need help. And yet, by comparison with the costs of not providing these services, pain clinics save a health system money – and this has been known since the 2000’s (Gatchel, McGeary, McGeary & Lippe, 2014; Loisel, Lemaire, Poitras, Durand, Champagne, Stock .et al, 2002).

The saddest thing about the proposal to cut funding is that by losing skilled and experienced – and passionate – clinicians, we all lose. Community pain services in New Zealand are largely staffed by clinicians who have little/no additional training in persistent pain. It’s well-documented that physiotherapists find it hard to identify and work with psychosocial factors – the main predictors for long-term distress and disability. Psychology programmes in New Zealand have little/no pain content. There are too few pain specialists. And most of the community pain services pay lip service to interprofessional teamwork because they’re not co-located, haven’t developed effective team structures because these are considered a “cost” to service delivery by private owners, and use contractors who are not paid to attend meetings.

New Zealand’s population is aging. Along with aging is an increase in painful conditions such as osteoarthritis and diabetic neuropathy (we have such high rates of diabetes). We have no national pain strategy. Our clinical workforce is under-skilled and many clinicians find pain management work is hard and demoralising. I can see why clinicians feel demoralised when what should be seen as essential services are in the sights of cost-cutting administrators.

Blyth, F. M., March, L. M., Brnabic, A. J., & Cousins, M. J. (2004). Chronic pain and frequent use of health care. Pain, 111(1-2), 51-58.

Dueñas, M., Ojeda, B., Salazar, A., Mico, J. A., & Failde, I. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal of pain research, 9, 457.

Gatchel, R. J., McGeary, D. D., McGeary, C. A., & Lippe, B. (2014). Interdisciplinary chronic pain management: past, present, and future. American Psychologist, 69(2), 119.

Loisel, P., Lemaire, J., Poitras, S., Durand, M. J., Champagne, F., Stock, S., … & Tremblay, C. (2002). Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occupational and Environmental Medicine, 59(12), 807-815.