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.

Australia has often been called the “allergy capital of the world”.

An estimated one in ten Australian children develop a food allergy in their first 12 months of life. Research has previously suggested food allergies are more common in infants in Australia than infants living in Europe, the United States or Asia.

So why are food allergies so common in Australia? We don’t know exactly – but local researchers are making progress in understanding childhood allergies all the time.

What causes food allergies?

There are many different types of reactions to foods. When we refer to food allergies in this article, we’re talking about something called IgE-mediated food allergy. This type of allergy is caused by an immune response to a particular food.

Reactions can occur within minutes of eating the food and may include swelling of the face, lips or eyes, “hives” or welts on the skin, and vomiting. Signs of a severe allergic reaction (anaphylaxis) include difficulty breathing, swelling of the tongue, swelling in the throat, wheeze or persistent cough, difficulty talking or a hoarse voice, and persistent dizziness or collapse.

Recent results from Australia’s large, long-running food allergy study, HealthNuts, show one in ten one-year-olds have a food allergy, while around six in 100 children have a food allergy at age ten.

In Australia, the most common allergy-causing foods include eggs, peanuts, cow’s milk, shellfish (for example, prawn and lobster), fish, tree nuts (for example, walnuts and cashews), soybeans and wheat.

Allergies to foods like eggs, peanuts and cow’s milk often present for the first time in infancy, while allergies to fish and shellfish may be more common later in life. While most children will outgrow their allergies to eggs and milk, allergy to peanuts is more likely to be lifelong.

Findings from HealthNuts showed around three in ten children grew out of their peanut allergy by age six, compared to nine in ten children with an allergy to egg.

Are food allergies becoming more common?

Food allergies seem to have become more common in many countries around the world over recent decades. The exact timing of this increase is not clear, because in most countries food allergies were not well measured 40 or 50 years ago.

We don’t know exactly why food allergies are so common in Australia, or why we’re seeing a rise around the world, despite extensive research.

But possible reasons for rising allergies around the world include changes in the diets of mothers and infants and increasing sanitisation, leading to fewer infections as well as less exposure to “good” bacteria. In Australia, factors such as increasing vitamin D deficiency among infants and high levels of migration to the country could play a role.

In several Australian studies, children born in Australia to parents who were born in Asia have higher rates of food allergies compared to non-Asian children. On the other hand, children who were born in Asia and later migrated to Australia appear to have a lower risk of nut allergies.

Meanwhile, studies have shown that having pet dogs and siblings as a young child may reduce the risk of food allergies. This might be because having pet dogs and siblings increases contact with a range of bacteria and other organisms.

This evidence suggests that both genetics and environment play a role in the development of food allergies.

We also know that infants with eczema are more likely to develop a food allergy, and trials are underway to see whether this link can be broken.

Can I do anything to prevent food allergies in my kids?

One of the questions we are asked most often by parents is “can we do anything to prevent food allergies?”.

We now know introducing peanuts and eggs from around six months of age makes it less likely that an infant will develop an allergy to these foods. The Australasian Society of Clinical Immunology and Allergy introduced guidelines recommending giving common allergy-causing foods including peanut and egg in the first year of life in 2016.

Our research has shown this advice had excellent uptake and may have slowed the rise in food allergies in Australia. There was no increase in peanut allergies between 2007–11 to 2018–19.

Introducing other common allergy-causing foods in the first year of life may also be helpful, although the evidence for this is not as strong compared with peanuts and eggs.

What next?

Unfortunately, some infants will develop food allergies even when the relevant foods are introduced in the first year of life. Managing food allergies can be a significant burden for children and families.

Several Australian trials are currently underway testing new strategies to prevent food allergies. A large trial, soon to be completed, is testing whether vitamin D supplements in infants reduce the risk of food allergies.

Another trial is testing whether the amount of eggs and peanuts a mother eats during pregnancy and breastfeeding has an influence on whether or not her baby will develop food allergies.

For most people with food allergies, avoidance of their known allergens remains the standard of care. Oral immunotherapy, which involves gradually increasing amounts of food allergen given under medical supervision, is beginning to be offered in some facilities around Australia. However, current oral immunotherapy methods have potential side effects (including allergic reactions), can involve high time commitment and cost, and don’t cure food allergies.

There is hope on the horizon for new food allergy treatments. Multiple clinical trials are underway around Australia aiming to develop safer and more effective treatments for people with food allergies.

Jennifer Koplin, Group Leader, Childhood Allergy & Epidemiology, The University of Queensland and Desalegn Markos Shifti, Postdoctoral Research Fellow, Child Health Research Centre, Faculty of Medicine, The University of Queensland

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