This week’s ABC Four Corners episode Pain Factory 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 Australians aged 45 and over have chronic pain (pain lasting three or more months). This costs an estimated A$139 billion a year, 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?

Opioids and invasive procedures

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

Spinal fusion surgery and spinal cord stimulators 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 and World Health Organization 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 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 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 $90–$150.

In contrast, Medicare 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, 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, for example, is higher in regional Australia and in areas of socioeconomic disadvantage than metropolitan centres and affluent areas.

So what can we do about it?

We need to reform Australia’s health system, private and public, 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, 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 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.

Christine Lin, Professor, University of Sydney; Christopher Maher, Professor, Sydney School of Public Health, University of Sydney; Fiona Blyth, Professor, University of Sydney; James Mcauley, Professor of Psychology, UNSW Sydney, and Mark Hancock, Professor of Physiotherapy, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Last week, the Australian Therapeutic Goods Administration added intravenous (IV) fluids to the growing list of medicines in short supply. The shortage is due to higher-than-expected demand and manufacturing issues.

Two particular IV fluids are affected: saline and compound sodium lactate (also called Hartmann’s solution). Both fluids are made with salts.

There are IV fluids that use other components, such as sugar, rather than salt. But instead of switching patients to those fluids, the government has chosen to approve salt-based solutions by other overseas brands.

So why do IV fluids contain different chemicals? And why can’t they just be interchanged when one runs low?

We can’t just inject water into a vein

Drugs are always injected into veins in a water-based solution. But we can’t do this with pure water, we need to add other chemicals. That’s because of a scientific principle called osmosis.

Osmosis occurs when water moves rapidly in and out of the cells in the blood stream, in response to changes to the concentration of chemicals dissolved in the blood plasma. Think salts, sugars, nutrients, drugs and proteins.

Too high a concentration of chemicals and protein in your blood stream leads it to being in a “hypertonic” state, which causes your blood cells to shrink. Not enough chemicals and proteins in your blood stream causes your blood cells to expand. Just the right amount is called “isotonic”.

Mixing the drug with the right amount of chemicals, via an injection or infusion, ensures the concentration inside the syringe or IV bag remains close to isotonic.

What are the different types of IV fluids?

There are a range of IV fluids available to administer drugs. The two most popular are:

• 0.9% saline, which is an isotonic solution of table salt. This is one of the IV fluids in short supply
• a 5% solution of the sugar glucose/dextrose. This fluid is not in short supply.

There are also IV fluids that combine both saline and glucose, and IV fluids that have other salts:

• Ringer’s solution is an IV fluid which has sodium, potassium and calcium salts
• Plasma-Lyte has different sodium salts, as well as magnesium
• Hartmann’s solution (compound sodium lactate) contains a range of different salts. It is generally used to treat a condition called metabolic acidosis, where patients have increased acid in their blood stream. This is in short supply.

What if you use the wrong solution?

Some drugs are only stable in specific IV fluids, for instance, only in salt-based IV fluids or only in glucose.

Putting a drug into the wrong IV fluid can potentially cause the drug to “crash out” of the solution, meaning patients won’t get the full dose.

Or it could cause the drug to decompose: not only will it not work, but it could also cause serious side effects.

An example of where a drug can be transformed into something toxic is the cancer chemotherapy drug cisplatin. When administered in saline it is safe, but administration in pure glucose can cause life-threatening damage to a patients’ kidneys.

What can hospitals use instead?

The IV fluids in short supply are saline and Hartmann’s solution. They are provided by three approved Australian suppliers: Baxter Healthcare, B.Braun and Fresenius Kabi.

The government’s solution to this is to approve multiple overseas-registered alternative saline brands, which they are allowed to do under current legislation without it going through the normal Australian quality checks and approval process. They will have received approval in their country of manufacture.

The government is taking this approach because it may not be effective or safe to formulate medicines that are meant to be in saline into different IV fluids. And we don’t have sufficient capacity to manufacture saline IV fluids here in Australia.

The Australian Society of Hospital Pharmacists provides guidance to other health staff about what drugs have to go with which IV fluids in their Australian Injectable Drugs Handbook. If there is a shortage of saline or Hartmann’s solution, and shipments of other overseas brands have not arrived, this guidance can be used to select another appropriate IV fluid.

Why don’t we make it locally?

The current shortage of IV fluids is just another example of the problems Australia faces when it is almost completely reliant on its critical medicines from overseas manufacturers.

Fortunately, we have workarounds to address the current shortage. But Australia is likely to face ongoing shortages, not only for IV fluids but for any medicines that we rely on overseas manufacturers to produce. Shortages like this put Australian lives at risk.

In the past both myself, and others, have called for the federal government to develop or back the development of medicines manufacturing in Australia. This could involve manufacturing off-patent medicines with an emphasis on those medicines most used in Australia.

Not only would this create stable, high technology jobs in Australia, it would also contribute to our economy and make us less susceptible to future global drug supply problems.

Nial Wheate, Professor and Director Academic Excellence, Macquarie University and Shoohb Alassadi, Casual academic, pharmaceutical sciences, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Reports have recently emerged that solariums, or sunbeds – largely banned in Australia because they increase the risk of skin cancer – are being rebranded as “collarium” sunbeds (“coll” being short for collagen).

Commercial tanning and beauty salons in Queensland, New South Wales and Victoria are marketing collariums, with manufacturers and operators claiming they provide a longer lasting tan and stimulate collagen production, among other purported benefits.

A collarium sunbed emits both UV radiation and a mix of visible wavelength colours to produce a pink or red light. Like an old-school sunbed, the user lies in it for ten to 20 minute sessions to quickly develop a tan.

But as several experts have argued, the providers’ claims about safety and effectiveness don’t stack up.

Why were sunbeds banned?

Commercial sunbeds have been illegal across Australia since 2016 (except for in the Northern Territory) under state-based radiation safety laws. It’s still legal to sell and own a sunbed for private use.

Their dangers were highlighted by young Australians including Clare Oliver who developed melanoma after using sunbeds. Oliver featured in the No Tan Is Worth Dying For campaign and died from her melanoma at age 26 in 2007.

Sunbeds lead to tanning by emitting UV radiation – as much as six times the amount of UV we’re exposed to from the summer sun. When the skin detects enough DNA damage, it boosts the production of melanin, the brown pigment that gives you the tanned look, to try to filter some UV out before it hits the DNA. This is only partially successful, providing the equivalent of two to four SPF.

Essentially, if your body is producing a tan, it has detected a significant amount of DNA damage in your skin.

Research shows people who have used sunbeds at least once have a 41% increased risk of developing melanoma, while ten or more sunbed sessions led to a 100% increased risk.

In 2008, Australian researchers estimated that each year, sunbeds caused 281 cases of melanoma, 2,572 cases of squamous cell carcinoma (another common type of skin cancer), and $3 million in heath-care costs, mostly to Medicare.

How are collarium sunbeds supposed to be different?

Australian sellers of collarium sunbeds imply they are safe, but their machine descriptions note the use of UV radiation, particularly UVA.

UVA is one part of the spectrum of UV radiation. It penetrates deeper into the skin than UVB. While UVB promotes cancer-causing mutations by discharging energy straight into the DNA strand, UVA sets off damage by creating reactive oxygen species, which are unstable compounds that react easily with many types of cell structures and molecules. These damage cell membranes, protein structures and DNA.

Evidence shows all types of sunbeds increase the risk of melanoma, including those that use only UVA.

Some manufacturers and clinics suggest the machine’s light spectrum increases UV compatibility, but it’s not clear what this means. Adding red or pink light to the mix won’t negate the harm from the UV. If you’re getting a tan, you have a significant amount of DNA damage.

Collagen claims

One particularly odd claim about collarium sunbeds is that they stimulate collagen.

Collagen is the main supportive tissue in our skin. It provides elasticity and strength, and a youthful appearance. Collagen is constantly synthesised and broken down, and when the balance between production and recycling is lost, the skin loses strength and develops wrinkles. The collagen bundles become thin and fragmented. This is a natural part of ageing, but is accelerated by UV exposure.

The reactive oxygen species generated by UVA light damage existing collagen structures and kick off a molecular chain of events that downgrades collagen-producing enzymes and increases collagen-destroying enzymes. Over time, a build-up of degraded collagen fragments in the skin promotes even more destruction.

While there is growing evidence red light therapy alone could be useful in wound healing and skin rejuvenation, the UV radiation in collarium sunbeds is likely to undo any benefit from the red light.

What about phototherapy?

There are medical treatments that use controlled UV radiation doses to treat chronic inflammatory skin diseases like psoriasis.

The anti-collagen effects of UVA can also be used to treat thickened scars and keloids. Side-effects of UV phototherapy include tanning, itchiness, dryness, cold sore virus reactivation and, notably, premature skin ageing.

These treatments use the minimum exposure necessary to treat the condition, and are usually restricted to the affected body part to minimise risks of future cancer. They are administered under medical supervision and are not recommended for people already at high risk of skin cancer, such as people with atypical moles.

So what happens now?

It looks like many collariums are just sunbeds rebranded with red light. Queensland Health is currently investigating whether these salons are breaching the state’s Radiation Safety Act, and operators could face large fines.

As the 2024 Australians of the Year – melanoma treatment pioneers Georgina Long and Richard Scolyer – highlighted in their acceptance speech, “there is nothing healthy about a tan”, and we need to stop glamorising tanning.

However, if you’re desperate for the tanned look, there is a safer and easy way to get one – out of a bottle or by visiting a salon for a spray tan.

Katie Lee, PhD Candidate, Dermatology Research Centre, The University of Queensland and Anne Cust, Professor of Cancer Epidemiology, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.