Surgery won’t fix my chronic back pain, so what will?

This week’s ABC Four Corners episode Pain Factory^[1] highlighted that our health system is failing Australians with chronic pain. Patients are receiving costly, ineffective and risky care instead of effective, low-risk treatments for chronic pain.

The challenge is considering how we might reimagine health-care delivery so the effective and safe treatments for chronic pain are available to millions of Australians who suffer from chronic pain.

One in five^[2] Australians aged 45 and over have chronic pain (pain lasting three or more months). This costs an estimated A$139 billion a year^[3], including $12 billion in direct health-care costs.

The most common complaint among people with chronic pain is low back pain. So what treatments do – and don’t – work?

Read more: Evidence doesn't support spinal cord stimulators for chronic back pain – and they could cause harm^[4]

Opioids and invasive procedures

Treatments offered to people with chronic pain include strong pain medicines such as opioids^[5] and invasive procedures such as spinal cord stimulators^[6] or spinal fusion surgery^[7]. Unfortunately, these treatments have little if any benefit and are associated with a risk of significant harm.

Spinal fusion surgery^[8] and spinal cord stimulators^[9] are also extremely costly procedures, costing tens of thousands of dollars each to the health system as well as incurring costs to the individual.

Addressing the contributors to pain

Recommendations from the latest Australian^[10] and World Health Organization^[11] clinical guidelines for low back pain focus on alternatives to drug and surgical treatments such as:

• education
• advice
• structured exercise programs
• physical, psychological or multidisciplinary interventions that address the physical or psychological contributors to ongoing pain.

Two recent Australian trials support these recommendations and have found that interventions that address each person’s physical and psychological contributors to pain produce large and sustained improvements in pain and function in people with chronic low back pain.

The interventions have minimal side effects and are cost-effective.

In the RESOLVE^[13] trial, the intervention consists of pain education and graded sensory and movement “retraining” aimed to help people understand that it’s safe to move.

In the RESTORE^[14] trial, the intervention (cognitive functional therapy) involves assisting the person to understand the range of physical and psychological contributing factors related to their condition. It guides patients to relearn how to move and to build confidence in their back, without over-protecting it.

Why isn’t everyone with chronic pain getting this care?

While these trials provide new hope for people with chronic low back pain, and effective alternatives to spinal surgery and opioids, a barrier for implementation is the out-of-pocket costs. The interventions take up to 12 sessions, lasting up to 26 weeks. One physiotherapy session can cost^[15] $90–$150.

In contrast, Medicare^[16] provides rebates for just five allied health visits (such as physiotherapists or exercise physiologists) for eligible patients per year, to be used for all chronic conditions.

Private health insurers also limit access to reimbursement for these services by typically only covering a proportion of the cost and providing a cap on annual benefits. So even those with private health insurance would usually have substantial out-of-pocket costs.

Access to trained clinicians is another barrier. This problem is particularly evident in regional and rural Australia^[17], where access to allied health services, pain specialists and multidisciplinary pain clinics is limited.

Higher costs and lack of access are associated with the increased use of available and subsidised treatments, such as pain medicines, even if they are ineffective and harmful. The rate of opioid use^[18], for example, is higher in regional Australia and in areas of socioeconomic disadvantage than metropolitan centres and affluent areas.

Read more: Opioids don't relieve acute low back or neck pain – and can result in worse pain, new study finds^[19]

So what can we do about it?

We need to reform Australia’s health system, private and public^[20], to improve access to effective treatments for chronic pain, while removing access to ineffective, costly and high-risk treatments.

Better training of the clinical workforce, and using technology such as telehealth and artificial intelligence to train clinicians or deliver treatment may also improve access to effective treatments. A recent Australian trial^[21], for example, found telehealth delivered via video conferencing was as effective as in-person physiotherapy consultations for improving pain and function in people with chronic knee pain.

Advocacy and improving the public’s understanding^[22] of effective treatments for chronic pain may also be helpful. Our hope is that coordinated efforts will promote the uptake of effective treatments and improve the care of patients with chronic pain.

Read more: How long does back pain last? And how can learning about pain increase the chance of recovery?^[23]

References

1. ^{^} Pain Factory (www.abc.net.au)
2. ^{^} One in five (www.aihw.gov.au)
3. ^{^} A$139 billion a year (www.aihw.gov.au)
4. ^{^} Evidence doesn't support spinal cord stimulators for chronic back pain – and they could cause harm (theconversation.com)
5. ^{^} opioids (pubmed.ncbi.nlm.nih.gov)
6. ^{^} spinal cord stimulators (pubmed.ncbi.nlm.nih.gov)
7. ^{^} spinal fusion surgery (onlinelibrary.wiley.com)
8. ^{^} Spinal fusion surgery (bmchealthservres.biomedcentral.com)
9. ^{^} spinal cord stimulators (privatehealthcareaustralia.org.au)
10. ^{^} Australian (www.safetyandquality.gov.au)
11. ^{^} World Health Organization (www.who.int)
12. ^{^} Monkey Business Images/Shutterstock (www.shutterstock.com)
13. ^{^} RESOLVE (jamanetwork.com)
14. ^{^} RESTORE (pubmed.ncbi.nlm.nih.gov)
15. ^{^} can cost (www.sira.nsw.gov.au)
16. ^{^} Medicare (www.servicesaustralia.gov.au)
17. ^{^} regional and rural Australia (www.ruralhealth.org.au)
18. ^{^} rate of opioid use (www.safetyandquality.gov.au)
19. ^{^} Opioids don't relieve acute low back or neck pain – and can result in worse pain, new study finds (theconversation.com)
20. ^{^} public (www.health.gov.au)
21. ^{^} trial (pubmed.ncbi.nlm.nih.gov)
22. ^{^} improving the public’s understanding (pubmed.ncbi.nlm.nih.gov)
23. ^{^} How long does back pain last? And how can learning about pain increase the chance of recovery? (theconversation.com)