ReviewPrioritising pain in policy making: The need for a whole systems perspective
Introduction
Pain represents a major clinical, social and economic problem, and differences in definition and classification have perhaps tended to cloud the full extent of the burden of pain and pain-related disability. Traditional approaches to estimating the economic burden of disease, based on incidence and prevalence, fail to do justice to the wide-reaching consequences emanating from pain and the quality of its management. The distressing nature of pain and its impact on daily life, well-being and work makes it extremely difficult to quantify precisely. In this review, estimates of the burden and cost of pain from a variety of perspectives are provided, and the implications of this for prioritising pain in government policies are discussed.
For a number of people, pain is a more or less permanent feature of their lives, extends well beyond the acute phase and has a profound impact on their quality of life. Estimates of the prevalence of chronic pain, for example, range from 8% to 60% and over [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], due in part to the differences in the methodologies adopted in determining prevalence and the different populations studied. What is evident however is that chronic pain poses a profound challenge to the medical community [12] and, the fact that it is frequently accompanied by other symptoms, such as depression, anxiety, physical dysfunction and social isolation [13], [14] makes its management even more difficult. From a wider perspective, chronic pain has a major impact on labour market participation, affects performance and productivity and is one of the major reasons why people exit labour markets prematurely, with highly significant consequences for employers and benefit agencies alike. Yet despite these effects, pain and its management do not feature prominently in government health policies and priorities.
The bio-psychosocial model, which has been used to explain and manage conditions classified as musculoskeletal problems [15], [16], has also helped to clarify thinking about the development of chronicity, and has highlighted benefits of earlier intervention and targeting of modifiable risk factors for chronicity. Nonetheless, there remains the need to broaden this approach to explore the wider determinants of health. The proposed adoption of a much wider, strategic perspective in relation to pain and its management, based on the three E's of effectiveness, efficiency and equity [17] has not materialised. Furthermore, deficiencies in relation to policies and service provision have highlighted the existence of a fourth E—that of ethics, linked with the need for appropriate strategies to be established to reduce the risk of professional and legal action [18].
It is our contention that a significant divergence exists between chronic pain, as viewed from current policy perspectives, and chronic pain viewed in its biopsychosocial context. In addressing this deficiency in policy our specific objectives are to:
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integrate and appraise current evidence on the burden of chronic pain (which is used in this paper as a generic term, based on the IASP (1986) definition of chronic pain [19]), and its effects on health services, employers, benefit agencies and individuals’ quality of life;
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assess suitability and relevance of current policy initiatives in relation to the management of pain and disability; and
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offer a series of recommendations for developing a broader agenda within which to address the problem of chronic pain in both its clinical and wider social context.1
Section snippets
Costs to employers
The economic impact of pain is greater than most other health conditions [20], [21], due to its effects on rates of absenteeism, reduced productivity and risk of leaving the labour market. In Sweden is has been suggested that the loss of production due to sick leave resulting from chronic pain constituted 91% of the socioeconomic cost of SEK 87.5 billion (€9.2 billion) associated with the problem in 2003 [21]. The effect of pain, and in particular pain exacerbations, was also evident in a USA
Pain and its impact on quality of life
Pain affects everyone to varying degrees. For some it may be the briefest of acute sensations, but for others it becomes a permanent feature of their lives and its effects on well-being can be wide reaching, leading to depression, sleep disturbance and fatigue, decrements in physical and cognitive functioning, and changes in the mood, personality, and social relationships of the sufferer [35].
In the UK, based on a prevalence of chronic pain of 10% [36], it has been estimated that there are
Approaches to patient management
As indicated above, estimates of the costs to health services resulting from pain and its management vary between countries partly due to differences in patient management and treatment approaches [31].
In the clinical management of mechanical low back pain, once the relatively rare ‘red flags’ for serious pathology have been ruled out, referral for imaging or orthopaedic surgery is not recommended [46], [47]. However, as around 90% of patients presenting with back pain have non-specific back
A whole systems approach to the management of chronic pain
This review has demonstrated the wide-reaching impact of chronic pain on patients, employers and society as a whole. However, attempts to address these issues have been often frustrated by the lack of adequate and appropriate policy frameworks to enable people with chronic pain conditions to be effectively and efficiently managed, with what has been termed ‘budgetary myopia’ [70], a feature of decision-making in this area. Such narrow budgetary-focused approaches fail to grasp the consequences
Conclusion—a way forward?
Based on the evidence presented in this review, the following recommendations are made on how to increase the priority attached to pain and its management in policy making and how resources should be reallocated to reduce the real costs of pain.
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Policies need to prioritise improvements in:
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the provision of pain services;
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provision of appropriate training and support for primary care staff, in the early recognition of the precursors of chronic pain, in identification of the markers of unnecessary
Acknowledgements
We acknowledge the comments offered by Dr. Michael von Korff on an earlier version and the helpful suggestions of the two anonymous referees.
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