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.

It’s a shock when we realise our parents aren’t managing well at home.

Perhaps the house and garden are looking more chaotic, and Mum or Dad are relying more on snacks than nutritious meals. Maybe their grooming or hygiene has declined markedly, they are socially isolated or not doing the things they used to enjoy. They may be losing weight, have had a fall, aren’t managing their medications correctly, and are at risk of getting scammed.

You’re worried and you want them to be safe and healthy. You’ve tried to talk to them about aged care but been met with swift refusal and an indignant declaration “I don’t need help – everything is fine!” Now what?

Here are four things to consider.

1. Start with more help at home

Getting help and support at home can help keep Mum or Dad well and comfortable without them needing to move.

Consider drawing up a roster of family and friends visiting to help with shopping, cleaning and outings. You can also use home aged care services – or a combination of both.

Government subsidised home care services provide from one to 13 hours of care a week. You can get more help if you are a veteran or are able to pay privately. You can take advantage of things like rehabilitation, fall risk-reduction programs, personal alarms, stove automatic switch-offs and other technology aimed at increasing safety.

Call My Aged Care to discuss your options.

2. Be prepared for multiple conversations

Getting Mum or Dad to accept paid help can be tricky. Many families often have multiple conversations around aged care before a decision is made.

Ideally, the older person feels supported rather than attacked during these conversations.

Some families have a meeting, so everyone is coming together to help. In other families, certain family members or friends might be better placed to have these conversations – perhaps the daughter with the health background, or the auntie or GP who Mum trusts more to provide good advice.

Mum or Dad’s main emotional support person should try to maintain their relationship. It’s OK to get someone else (like the GP, the hospital or an adult child) to play “bad cop”, while a different person (such as the older person’s spouse, or a different adult child) plays “good cop”.

3. Understand the options when help at home isn’t enough

If you have maximised home support and it’s not enough, or if the hospital won’t discharge Mum or Dad without extensive supports, then you may be considering a nursing home (also known as residential aged care in Australia).

Every person has a legal right to choose where we live (unless they have lost capacity to make that decision).

This means families can’t put Mum or Dad into residential aged care against their will. Every person also has the right to choose to take risks. People can choose to continue to live at home, even if it means they might not get help immediately if they fall, or eat poorly. We should respect Mum or Dad’s decisions, even if we disagree with them. Researchers call this “dignity of risk”.

It’s important to understand Mum or Dad’s point of view. Listen to them. Try to figure out what they are feeling, and what they are worried might happen (which might not be rational).

Try to understand what’s really important to their quality of life. Is it the dog, having privacy in their safe space, seeing grandchildren and friends, or something else?

Older people are often understandably concerned about losing independence, losing control, and having strangers in their personal space.

Sometimes families prioritise physical health over psychological wellbeing. But we need to consider both when considering nursing home admission.

Research suggests going into a nursing home temporarily increases loneliness, risk of depression and anxiety, and sense of losing control.

Mum and Dad should be involved in the decision-making process about where they live, and when they might move.

Some families start looking “just in case” as it often takes some time to find the right nursing home and there can be a wait.

After you have your top two or three choices, take Mum or Dad to visit them. If this is not possible, take pictures of the rooms, the public areas in the nursing home, the menu and the activities schedule.

We should give Mum or Dad information about their options and risks so they can make informed (and hopefully better) decisions.

For instance, if they visit a nursing home and the manager says they can go on outings whenever they want, this might dispel a belief they are “locked up”.

Having one or two weeks “respite” in a home may let them try it out before making the big decision about staying permanently. And if they find the place unacceptable, they can try another nursing home instead.

4. Understand the options if a parent has lost capacity to make decisions

If Mum or Dad have lost capacity to choose where they live, family may be able to make that decision in their best interests.

If it’s not clear whether a person has capacity to make a particular decision, a medical practitioner can assess for that capacity.

Mum or Dad may have appointed an enduring guardian to make decisions about their health and lifestyle decisions when they are not able to.

An enduring guardian can make the decision that the person should live in residential aged care, if the person no longer has the capacity to make that decision themselves.

If Mum or Dad didn’t appoint an enduring guardian, and have lost capacity, then a court or tribunal can appoint that person a private guardian (usually a family member, close friend or unpaid carer).

If no such person is available to act as private guardian, a public official may be appointed as public guardian.

Deal with your own feelings

Families often feel guilt and grief during the decision-making and transition process.

Families need to act in the best interest of Mum or Dad, but also balance other caring responsibilities, financial priorities and their own wellbeing.

Lee-Fay Low, Professor in Ageing and Health, University of Sydney

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