I don’t envy the job of health economists – nor policy-makers or politicians who need to make the difficult decisions about who should receive allocation within the restricted health funding that is available. At the same time, I’m often worried when I hear that ‘high-tech’ treatments, and those that are perceived as ‘glamour’ health problems get funding when low-status problems like chronic pain get overlooked. So it was nice to read that Norway has enshrined the rights of people to receive evaluation and treatment for chronic pain within law.
The National Guidelines for chronic pain ‘seek to answer the difficult questions of which patients should be prioritised at pain clinics and what is a medically acceptable waiting time.’ It has been developed by ‘a task force established by the Directorate of Health, comprising pain specialists, primary care and patient representatives’ and has ‘identified 5 categories of complex pain disorders that as a main rule should be given the right to prioritised health care in pain clinics.’
The five categories are:
Category 1: Sub-acute (≤6 months) pain conditions with reason to fear chronification. Maximum waiting time 2 weeks, e.g., progressing complex regional pain syndrome (CRPS) 5 months after an ankle-fracture.
Category 2: Chronic complex pain condition, with or without known initiating cause, combined with substance abuse and/or psychiatric illness. These patients need concomitant follow-up by psychiatric
and/or addiction medicine department(s) and a multidisciplinary pain clinic approach. Maximum waiting time 16 weeks, e.g., CRPS of an arm combined with depression and addiction to heroin.
Category 3: Chronic complex pain condition WITH known initiating cause (that can no longer be treated with a curative approach). Maximum waiting time 16 weeks, e.g., Post-herpetic neuralgia.
Category 4: Chronic complex pain condition WITHOUT known initiating cause. Maximum waiting time 16 weeks, e.g., chronic muscle pain syndrome.
Category 5: Severe and difficult to treat pain condition in patients suffering from a known serious and advanced illness. Maximum waiting time 2 weeks, e.g., advanced cancer, COLD, heart failure, end stage
Several aspects of these guidelines strike me, and I’ll briefly outline them below.
The first is, that it’s great to see sub-acute pain problems prioritised for access ‘if there is reason to fear chronification’. While I chuckled a little at the term ‘chronification’, the concept of prioritising ‘at risk’ people is both not new, and strongly endorsed by many. What might be difficult to ascertain is who falls into this category and how they might be identified. We do know that the majority of risk factors are not biomedical, but are instead psychosocial – and this suggests that someone (probably the GP) would have to identify these psychosocial factors. A recent study I read suggested that while GP’s do identify psychosocial factors readily, the content of their conversations with these people is more biomedical than for those who don’t have these features in their presentation. Somehow I think GP’s and other primary providers need support to feel confident in how to identify and more importantly, manage people who are at high risk for chronic disability.
Next point is that category two includes patients who are often not prioritised – those with pre-existing psychiatric or addiction problems. In fact, often these patients bounce from service to service with none of the services wanting to take them on – these guidelines recommend a combined approach of both multidisciplinary pain management and concurrent psychiatric and addiction services help.
I mused on the distinction between people with pain with a presumed cause, and those without a presumed cause. While both were prioritised to be seen within 16 weeks of referral, I wasn’t sure why the two were separated – except maybe to suggest that biomedical management needs to be completed prior to referral for pain management. I’m not sure I totally agree with this because it’s well known that psychosocial factors influence chronic disability, but then again, it’s equally important that people are ready to acknowledge and accept that their pain is ongoing so that they can stop the search for a cure.
My final pondering is over the use of medical diagnoses with only limited reference to psychological and even less attention paid to social factors as a reason for prioritising people. After all, it’s not the diagnosis that causes people to go to a doctor – it’s that they can’t sleep, feel horrid, are really worried and may be about to lose their job, their family life and their relationships! I’d like to see priorities based much more upon these factors and the distress associated with this than on a diagnostic label.
I strongly endorse this section that underpins the rationale for seeing people at a specialist chronic pain management centre:
The cost of the specialised treatment offered has to be “reasonable” considering the expected outcome of the health care
provided. Chronic pain patients are avid users of health care services.
Patients with complex chronic pain conditions can be helped through a limited number of consultations at a multidisciplinary pain clinic. Health care costs can also be reduced considerably by avoiding further futile investigations and attempts at treatment (in other sectors of the health care system).
People with chronic pain use health services much more when they’re distressed, anxious, feel dismissed and misunderstood – and when they feel helpless and demoralised because they don’t know what to do with themselves. Something pain management centres do when they work well (perhaps following those ‘back to basics’ that I posted about yesterday), is reduce distress, increase function and help people feel more at ease with themselves despite experiencing ongoing pain.
Hara, K., & Borchgrevink, P. (2010). National guidelines for evaluating pain—Patients’ legal right to prioritised health care at multidisciplinary pain clinics in Norway implemented 2009 Scandinavian Journal of Pain, 1 (1), 60-63 DOI: 10.1016/j.sjpain.2009.10.002