Call for overhaul of pain medicine funding as more patients head for emergency departments

One of Australia’s leading pain medicine specialists has called for better allocation of resources to support comprehensive pain management services for inpatients and emergency departments with complex care needs in both private and public hospitals.

Dr Jane Trinca, the Director of the Barbara Walker Pain Centre at Melbourne’s St Vincent’s Hospital is speaking at the annual meeting of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists in Torquay, Victoria on Saturday September 23.
Dr Trinca, who co-edited the last edition of Acute Pain Management Scientific Evidence, a key reference manual used by Australian, New Zealand and international clinicians said more complex pain patients were presenting with multiple medical and psycho social and addiction conditions in public hospital emergency wards but funding and systemic constraints meant many were not receiving the appropriate treatment they needed.
The loss of psychiatric outpatient services in Victorian hospitals had also exacerbated the problem.
“Patients with painful conditions that are not amenable to surgery often have complex presentations that require a holistic approach and some need much more input from mental health and addiction and rehabilitation services. Pain medicine is a specialty that can bring these services together but it is not adequately recognised or resourced to provide an adequate service in an acute hospital setting,” she explained.
“Whilst it is appreciated that pouring more money into health is just not doable it needs to be said that a purely medical approach to these patients is not only ineffective but costs bed days and causes overuse of resources. Some patients are accessing multiple hospitals to seek care so a more patient-centred approach may actually save money.”
Dr Trinca said there was a need for skilled practitioners to be available and funded to provide care that “may be complex and costly and often non-medical and difficult to explain to those in charge of budgets”.
“Embracing such changes in our health system could result in significant savings for the healthcare system and provide much better and safer care for the individual patient,” she said.
Dr Trinca cited the case of a 63 year old female patient who had spent nearly 10 years navigating her way through the health system with chronic abdominal pain and severe anxiety only to undergo surgery to remove her lower bowel in the belief that it would relieve her pain. The pain remained after the operation.
“This patient was followed over a period of years. She had acute episodes of abdominal pain due to an irritable bowel and constipation but she came into hospital by ambulance multiple times. There were multiple investigations and she had many panic attacks. Often these patients are treated dismissively and they get put on medications that make them feel unwell and make their problem worse.
“The pain she was experiencing remained after the operation because she actually had chronic constipation and irritable bowel syndrome. She got so caught up in the system and shopped around before she finally saw a surgeon who said her pain would disappear if she had the operation.”
“People love hearing they are going to get fixed and they think their life will be great. She then had this big surgery and there was complete desolation when it didn’t work.’’
The woman is now responding well to a pain management plan that involved education, breathing techniques, transcutaneous electrical nerve stimulation and bowel training with a physiotherapist and later there was input from psychologist and psychiatrist.
“Her life is now on a very different trajectory with this treatment plan which has seen her go gradually from strength to strength as she began to understand her condition and the many factors that contributed to it and has learned some skills to manage the acute episodes. If she had gone down those avenues earlier and been introduced to this approach consistently by her health practitioners at an earlier phase she may well have had a different result and saved the health system a large amount of money.”
Dr Trinca said she was concerned that pain medicine specialists and psychologists and psychiatrists generally worked in “silos” in public hospitals. Dr Trinca stressed however that her experience at St Vincent’s Hospital, where she has worked for nearly 20 years, is better than most but “there was this difficulty of pulling together a comprehensive program for these complex patients who get admitted”.
“It’s very patchy – not many hospitals have the ability to pull out a pain medicine specialist from an (on-site) clinic and send them into a ward. We do it sometimes but we don’t have funding to do it. If we see a patient in the ward we lose valuable activity that supports the outpatient service.
“It must be recognized that acute pain services which are available in some hospitals are staffed by highly experienced nursing staff, anaesthetists and pain medicine specialists and these services have made a big difference in identifying these complex patients. Much more could be done however if these services were better supported by pain medicine specialists and their treatment teams.
“The answer is not about putting these complex patients into hospital in an acute bed with nursing staff measuring their temperatures and vital signs. If they are admitted they need a treatment team with skills and time to really understand their needs. We really want to keep most of these patients out of hospital but unfortunately they get admitted for weeks on end and often there is not much to find on investigations that is treatable by surgery or medications.”
Dr Trinca said she supported the introduction of hospital data collection that could examine the scope and cost of unnecessary and inappropriate hospital admissions so treatment for patients with chronic pain flares or recurrent pain not amenable to surgery.
“We need to ensure these people don’t continue to fall through the cracks,” she said.
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