Pain Education in the Community

Dr Tim SempleRoyal Adelaide Hospital

Chronic Pain in South Australia – South Australian Health Omnibus Survey 2006

Currow et al. Aust NZ J Public Health.2010;34(3)

• Whole of population, face-to-face, 2973 interviewed

• Prevalence of chronic pain 17.9%

• Severe pain interfering severely with activity 5%

Chronic Pain in South Australia – South Australian Health Omnibus Survey 2006

Currow et al. Aust NZ J Public Health.2010;34(3)

240,000 adults with mild-moderate pain

65,000 adults with severe pain

Pain Clinic Service capacity - 2400 adults assessed annually

1% of the CNCP population !

Unmet Burden of Community Pain

Pain Clinic

Unmet Burden of Community Pain

Pain Clinic

System plasticity...... : informed consumers guide clinical reorientation and system reorganisation Davies, Hayes and Quintner. Pain Med 2011; 12

When systems fail to meet demands.....

• Allow change and plasticity

• Partner informed consumers with responsive professionals

STEPS - Preclinic group education sessions reduce waiting times and costs. Davies SJ et al. Pain Med 2011;12

Systematic redesign of traditional model of care of tertiary pain medicine unit – initial group rather than individual appointments

• Small group, 8 hours over 2 days - clinical psychology, occupational therapy, physiotherapy and pain medicine

• Outcomes– Waiting lists down to 16 weeks from 105 weeks– Costs per new patient appointed reduced from $1805 to $541– Positive patient satisfaction – Improved Global Perceived Impression of Change– Increased utilisation of active pain management strategies

Preclinic group education sessions reduce waiting times and costs. Davies SJ et al. Pain Med 2011;12

Interesting point

• Mean duration of pain prior to intervention – 9.2 years !

• Delivered by highly-specialised practitioners

STEPS - one option but just part of the bigger picture

Pain education in the community - improving capacity

• Health reform

• Mass Media

• Web-based information

• Pain self-management

• Support

National Health and Hospitals Reform Agenda – Final Report June 2009

Recommendations for a healthier future for all Australians....

10. We support strategies that help people take greater personal responsibility for improving their health through policies that ‘make healthy choices easy choices’.

11. We recommend that health literacy is included as a core element of the National Curriculum and that it is incorporated in national skills assessment. This should apply across primary and secondary schools.

12. We urge all relevant groups to provide access to evidence-based, consumer-friendly information that supports people in making healthy choices and in better understanding and making decisions about their use of health services......

Health Reform - National Pain Strategy 2010

Goal 2: Knowledgeable empowered and supported consumers

“Health literacy” – what is it ?

• The ability of a patient to navigate a healthcare system in a positive way

• To able to work in an equal partnership with care team

• To be a fully activated patient – undertaking necessary lifestyle changes to achieve optimum outcomes from treatment and disease management

“Health literacy” – just more jargon ?

Latest systematic review

Associated with lower health literacy are

– Increased hospitalisation– Greater use of emergency care– Poorer ability to take medications as directed

Berkman ND et al. Health Literacy Interventions and Outcomes: An Updated Systematic Review, . AHRQ Publication Number 11-E006-1, March 2011. Agency for Healthcare Research and Quality http://www.ahrq.gov/clinic/epcsums/litupsum.htm

Kaiser model of care for chronic conditions – 80/20

80% self-management:20% professional care

80%

20%

NHS focus on self-management for chronic conditions

Wanless Report 2002 – “Only one viable longterm option for NHS – citizens as partners in care and responsible for maintenance of physical and mental well-being”

• EPP trialled 2001-2004, mainstreamed 2004-2007

• Follow-up on 1000 patients involved in self-management

Expert Patient Program outcomes for chronic conditions

• Annual savings per individual $4000

• Greatest benefits in individuals with low impairment but high disability

• Improving health literacy achieved significant benefit

• Clinicians needed training in self-management as much as patients

Getting the message out there – mass media

• Mass media can be an effective tool

• Current mass media campaigns in Australia– Heart disease– Smoking– Osteoporosis– Obesity – etc etc etc

• Victorian WorkCover Authority back pain campaign 1997-99 highly effective – most cited for pain education

Grilli R. Mass media interventions: effects on health services utilisation. Cochrane Database 2002, Issue 1. .

Victorian WorkCover Back Pain campaign 1997-99

Goal – altering population attitudes and beliefs concerning back pain

• Delivered positive messages about back pain– Stay active– Normal daily activities– Avoid medicalisation and unnecessary diagnostic tests– Overcome fear-avoidance by gradually tackling difficult tasks – Be aware of “red flags”

September 1997 - intense 3 month TV commercial campaign followed by 9 month of low key maintenance

September 1999 – further 3 month intense TV campaign

Victorian WorkCover Back Pain campaign

Outcome

• Improved community attitudes and beliefs concerning LBP• Improved general practitioner attitudes and beliefs• Reduced claims and medical payments for LBP

Sustained changes for at least 4.5 years.......

Getting the message out there – mass media

Components of success

• Full range of approaches – TV, radio, billboard, bus, Web, Facebook

• Short sharp message delivered by creditable personalities

• Not too long, not too short – 3 months to 12 months duration

• Lots of money – close to $2 million

Pharmaceuticals and Mass Media - early direct to consumer advertising

ASPRO

“for treatment of pain AND depression”.......

More early direct to consumer advertising

Entrenching pharmaceuticals into the “national myth”

“Direct to Consumer Advertising” of medicines USA-style

• Significant impact in USA – “the wonder drug for the pharmaceutical industry”

• $2.5 billion advertising spending in 2000– 15% disease awareness– 85% in brand-specific – targets new high-cost drugs for long-term conditions

• New drug “samples” of $8 billion value provided to prescribers to meet consumer enquiries

DTCAreport, PHARM Committee, Australian Government DHA April 2004

im

Time MagazineMarch 21 2011

What is TIME telling consumers ?

• 76 millions US citizens with chronic pain – 80% undertreated

• Doctors – “We do it badly”

• Pain is a disease not a symptom

Net-based pain education from a govt-funded site!

Pain education tools direct from the consumer via the net

Pete Moore EPP

HIPS community pain information

RCT of community-based psychoeducational program for self-management of chronic pain

• Chronic pain adaption of arthritis self-management program (Kate Lorig, Stanford Patient Education Research Centre)

• Low-cost community-based 12 hour nurse-led program

• 110 individuals, mixed pain diagnoses, mean pain duration 6 yrs

• Significant improvements in pain, self-efficacy, vitality, life satisfaction

Sandra LeFort et al. Pain 74 (1998) 297-306

Calgary Pain Program

Integrating educational resources and community early access programs with primary and specialist services

Consumer organisation

Peer-led program for pain self-management

Based on Stanford model

Integrated with NHS Scotland with strong tertiary and primary links

Funding support from NHS

Who is providing support for consumers?

Consumers supporting consumers in Australia

APMA promoting self-management with UK expert patient champion to primary care

Consumers supporting consumers in Australia

Consumers supporting consumers in Australia

Old thinking

New thinking !

Combining

•E-newsletter•Consumer organisation•GP network•Tertiary pain service

Applying

•Scottish consumer-led self management programme•Derived from Stanford Chronic Condition programme

Pain and (Education in) the Community Sector

• Health reform is coming first to community sector – pain medicine needs to be there too

• Mass media pain campaign – when ?

• Early access self-management programs are effective... but which is best model ?

• Consumer pain organisations are leading change in the community sector

• Government responds to consumer messages foremost

New thinking