The costs for management of chronic pain in Australia are expected to rise in real terms. In 2019, Deloitte conducted a study that estimated the costs of pain management would rise from $139.3 billion (2018) to $215.6 billion in 20501. There are many elements to those costs and although the report is dated there has not been a similar one commissioned since. The scope of these costs is huge.
Yet when I went to the NSW State Insurance Regulatory Authority (SIRA) website and typed ‘pain management costs’, the most recent relevant article across both CTP and workers' compensation was from July 2020. There was plenty of information in guidelines etc. that was more recent but not considered by SIRA as relevant to my query. Perhaps I was not using the correct research technique or search terms. It may be SIRA has done more recent work, I just could not find it. SIRA relatively speaking may be advanced in their action on pain management as there was a 2010 national pain summit but nothing like that since. It seems pain management is too painful.
This SIRA July 2020 document was an ‘infographic’ and referred to SIRA participating in a study in conjunction with the University of Sydney and the John Walsh Centre for Rehabilitation Research. The aim of the study was: “To identify the current evidence relating to the better management of chronic pain in a compensable population”.
The infographic noted:
- In Australia about 20% of chronic pain sufferers receive workers compensation
- There may be factors inherent in compensation schemes that affect the experience of chronic pain
- Reduced employment associated with chronic pain was estimated to cost $36.2 billion in 2018
The results of the study in brief were:
- The evidence for medical interventions in chronic pain is weak
- Evidence exists for cognitive behavioural therapy and pain education (including online)
- The biopsychosocial model is considered best practice with a key component of active self-management
- There is evidence for a range of interventions for different pain conditions and different stages
- Cannabis-based medicines are not first-line treatment of any pain condition
Let’s turn to the first point, namely “the evidence for medical interventions in chronic pain is weak”. One example is the use of opiates. It is not uncommon in CTP claims to see the use of opiates for pain management. Sometimes the claim extends to the effect of addiction caused by the alleged medical need to take opiates for pain relief. Sometimes the claimant is prescribed so many opiates from so many doctors that Medicare steps in to warn GP’s the claimant is ‘doctor-shopping’. Then there may be the gastro-intestinal consequences from such medication. Doesn’t sound like there is much relief here, just getting worse and worse.
The people who provide excellent service at the Brisbane Pain Rehabilitation Service or the ADAPT program run by the Royal North Shore Hospital would say that interdisciplinary pain management (IPM) provides the best or at least improved outcomes2. Offering online pain management has also been effective3.
What about the biopsychosocial model, does that help? The 2018 SA CTP Injury Recovery and Early Intervention Framework helpfully set out the relevant ‘flags model’ for this4:
Mental Health Factors
Beliefs, appraisals and judgments
System or contextual obstacles
The above framework may be useful but, as an example, the experience in rural areas highlights the difficulties. Understanding pain and being able to treat pain do not necessarily go hand in hand. Multidisciplinary care, seen as excellent for pain management, does not exist in most rural areas which lack some of the necessary specialists: Carol Bennett, Painaustralia at the 2019 15th National Rural Health Conference, ‘The impact of pain on rural and regional Australia: problems and solutions’.
I will not address the fourth point regarding the range of interventions for different pain conditions and different stages other than to note this obviously contributes to the complexity of the problem.
The last dot point has been addressed in a decision dated 1 December 2021 by a Review Panel of the NSW Personal Injury Commission: Bradley v Allianz Australia Insurance LTD  NSWPICMP 226. The Panel refused payment for marijuana treatment to a claimant. This decision was based on the opinion of the Faculty of Pain Medicine of the Australia & New Zealand College of Anaesthetists. The statement from the Faculty (PS10(PM) 2021) was as follows:
“At the present time (November 2021), the scientific evidence for the efficacy of cannabinoids in the management of people with chronic non-cancer pain remains insufficient to justify endorsement of their clinical use”.
I do like history but is there not something more recent and of significant impact to pain management in CTP other than a useful decision on marijuana in 2021, a July 2020 infographic or a 2018 Framework based in part on a 2008 text? I am sure there is but none of this seems to be translating into action by the regulators of the CTP schemes. Instead, at the coalface, claimants and insurers alike are faced with an inadequate response with ever increasing cost. Perhaps Governments could use some of the revenue from CTP schemes to give more support to multi-disciplinary pain management in urban and, in particular, rural communities. I appreciate that comes at a cost to CTP premiums but this surely is far outweighed by the costs to the community from the effects of chronic pain.
What is obvious and should go without saying – but I’ll say it anyway – this is a complex issue and does not lend itself to a one size fits all solution. Quite the opposite. That complexity of course may feed the issue of pain management into a bureaucratic merry-go-round as far as CTP is concerned. If that were the case, it would be tragic. The treatment of pain is a basic human right.
1 Deloitte Access Economics, study for Painaustralia, “The cost of pain in Australia”, March 2019
2 See examples Day MA, Brinums M, Craig N, Geffen L, Geffen S, Lovai M and Geffen G, “Predictors of Responsivity to Interdisciplinary Pain Management”, in Pain Medicine Vol.19, Issue 9 September 2018 pp.1848-1861.
3 “Reboot Online: A Randomized Controlled Trial Comparing an Online Multidisciplinary Pain Management Program with Usual Care for Chronic Pain” in Pain Medicine Vol.20, Issue 12 December 2019 pp.2385-2396.
4 Based on Main, CJ, Sullivan, MJL and Watson, PJ, "Pain Management: practical applications of the biopsychosocial perspective in clinical and occupational settings", Churchill Livingstone, Edinburgh, New York 2008.