Chronic / prolonged pain management is not sexy. Nobody gets a magical cure. Lives are not saved – at least not as the mortality statistics show. Chronic pain treatment is underfunded.
Now, on a list of other proposed service cuts in the local health agency’s plan to save millions of dollars is a proposal to “save” $ 650,000 from the pain clinic. You will also see reductions in community services, GP support for vulnerable and healthy lifestyles.
I know that nurses, senior medical staff, and 200 administrative staff are also in the line of fire. I also know that this health agency has been wiped aside by the earthquake reconstruction, the terrorist attacks with so many victims in need of urgent and ongoing surgery and rehabilitation, and the psychological effects of all these events and now Covid-19 … delays and Poor finishing of new buildings on the main hospital grounds have resulted in these new facilities being way over budget and two years late – and there is still no parking for patients and staff. Due to historical underfunding by previous governments, Canterbury DHB has developed innovative and nimble responses to these challenges – and has received international praise for its work. I will not say anything about middle management growth. Suffice it to say that there used to be a general manager at one site and a direct line of report from the clinical director of a service – now there are three or four levels of management …
Let me discuss why reducing spending on pain services is more costly than saving.
Around 1987, a new pain management service was developed in Christchurch. One of the main reasons for opening this center was to cope with the growing increase in the number of people who presented for orthopedic surgery but who were not eligible for surgery. Either because the imaging couldn’t find anything – pain can’t be mapped and surgeons can’t do a normal X-ray or MRI scan – or because the person’s problem is unlikely to respond to surgery.
As a result of the new pain management service, individuals who were unsuitable for orthopedic surgery were referred for multidisciplinary pain management: medical assessment, functional assessment, psychosocial assessment, and appropriate Pain Management from there. As a result, fewer people with back pain were admitted to the orthopedic wards. Victory!
It is only possible in the first few years of a service to clearly demonstrate the impact on the rest of the health system. Why? Because it is not possible to show what is not Event. Having been around for many years, pain management services have made the impact invisible from those who visit these services, and not from other parts of the healthcare system.
For example, people who attend pain management services do not need as many ambulance rides, visits to the emergency room, and admissions to hospital emergencies. They do not stay in hospital beds while they investigate – while using bed space, “hotel services” (food, bedding, soap, towels, hot water, cleaning services) as well as qualified medical staff – doctors, nurses – physiotherapists, occupational therapists, laboratory technicians, phlebotomists , Radiographers, pharmacists and so on and so on …
People who are well cared for by pain services don’t take up that much space in the rest of the system – and the very people who need pain services are the people who otherwise do it do end up in many places throughout the healthcare system (Blyth, March, Brnabic, Cousins, 2004; Duenas, Ojeda, Salazar, Mico & Failde, 2016). So many epidemiological studies suggest that people with chronic pain will have an impact on “physical” health services, “mental” health services, primary care (general medicine), secondary care, and tertiary care. And an acute hospital setting is not the place to be when treating people with chronic pain.
Until recently, recordings for chronic pain were not counted as “chronic pain” because the coding used (ICD10) does not have chronic pain as a separate category. This means that, for example, a person with chronic abdominal pain has the condition listed in an acute pain inclusion category. Similar to chronic non-cardiac chest pain, these recordings are coded as “cardiac”. The new ICD11 will help reveal these currently hidden recordings – but currently it is not possible to identify how many people are seen in these departments but who could be better treated in a clinic for persistent pain.
Now, I’ll be the first to admit that our chronic pain treatments don’t have a massive impact. Pain intensity, disability and stress continue to affect people even after attending a pain service. BUT that’s the nature of a persistent pain problem – people don’t die from it, but like those with “Long-Covid19” they still need help. Yet pain clinics save money for the health system compared to the cost of not providing these services – and this has been known since the 2000s (Gatchel, McGeary, McGeary & Lippe, 2014; Loisel, Lemaire, Poitras, Durand, Champagne) Stock et al., 2002).
The saddest thing about the funding cut proposal is that if we lose skilled and experienced – and passionate – clinicians, we all lose. The New Zealand community pain services are largely staffed with clinicians who have little or no additional training in persistent pain. It is well documented that physical therapists find it difficult to identify and work with psychosocial factors – the most important predictors of long-term stress and disability. Psychology programs in New Zealand have little / no pain content. There are too few pain specialists. And most pain services in the community pay lip service to interprofessional teamwork because they are not based in the same place, have not developed effective team structures, because these are viewed as “costs” for the provision of services by private owners, and employ contractors to who do not get paid to attend meetings.
New Zealand’s population is aging. Along with aging, there is an increase in painful conditions like osteoarthritis and diabetic neuropathy (we have such high rates of diabetes). We don’t have a national pain strategy. Our clinical workforce is underqualified and many clinicians find pain management to be tough and demoralizing. I can see why clinicians feel demoralized when the cost reduction administrators see what should be considered essential services.
Blyth, FM, March, LM, Brnabic, AJ & Cousins, MJ (2004). Chronic pain and frequent health care use. Pain, 111(1-2), 51-58.
M. Dueñas, B. Ojeda, A. Salazar, JA Mico & I. Failde (2016). A review of the effects of chronic pain on patients, their social environment, and the healthcare system. Journal of Pain Research, 9457.
Gatchel, RJ, McGeary, DD, McGeary, CA & Lippe, B. (2014). Interdisciplinary management of chronic pain: past, present and future. American psychologist, 69(2), 119.
Loisel, P., Lemaire, J., Poitras, S., Durand, MJ, Champagne, F., Stock, S., … & Tremblay, C. (2002). Cost-benefit and cost-benefit analysis of a model for the prevention of disabilities in the treatment of back pain: a six-year follow-up study. Occupational and environmental medicine, 59(12), 807- 815.
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