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Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
RESEARCH ARTICLE (Open Access)

Health service utilisation by people living with chronic non-cancer pain: findings from the Pain and Opioids IN Treatment (POINT) study

Suzanne Nielsen A B G , Gabrielle Campbell A , Amy Peacock C , Kimberly Smith A , Raimondo Bruno A C , Wayne Hall D , Milton Cohen E and Louisa Degenhardt A F
+ Author Affiliations
- Author Affiliations

A National Drug and Alcohol Research Centre, UNSW, 22–32 King Street, Randwick, NSW 2031, Australia. Email: g.campbell@unsw.edu.au; kimberley.smith@unsw.edu.au

B South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, 591–623 S Dowling Street, Surry Hills, NSW 2010, Australia.

C School of Medicine, University of Tasmania, Private Bag 30, Hobart, Tas. 7001, Australia. Email: Amy.Peacock@utas.edu.au; Raimondo.Bruno@utas.edu.au

D Centre for Youth Substance Abuse Research, University of Queensland, Australia. Email: w.hall@uq.edu.au

E St Vincent’s Clinical School, UNSW Medicine, Level 5 deLacy Building, St Vincent’s Hospital, Victoria Street, Darlinghurst, NSW 2010, Australia. Email: M.Cohen@unsw.edu.au

F School of Population and Global Health, Level 4, 207 Bouverie Street, The University of Melbourne, Vic. 3010, Australia. Email: l.degenhardt@unsw.edu.au

G Corresponding author. Email: suzanne.nielsen@unsw.edu.au

Australian Health Review 40(5) 490-499 https://doi.org/10.1071/AH15047
Submitted: 9 March 2015  Accepted: 26 October 2015   Published: 25 November 2015

Journal Compilation © AHHA 2016

Abstract

Objective The aims of the present study were to describe the use, and barriers to the use, of non-medication pain therapies and to identify the demographic and clinical correlates of different non-opioid pain treatments.

Methods The study was performed on a cohort (n = 1514) of people prescribed pharmaceutical opioids for chronic non-cancer pain (CNCP). Participants reported lifetime and past month use of healthcare services, mental and physical health, pain characteristics, current oral morphine equivalent daily doses and financial and access barriers to healthcare services.

Results Participants reported the use of non-opioid pain treatments, both before and after commencing opioid therapy. Services accessed most in the past month were complementary and alternative medicines (CAMs; 41%), physiotherapy (16%) and medical and/or pain specialists (15%). Higher opioid dose was associated with increased financial and access barriers to non-opioid treatment. Multivariate analyses indicated being younger, female and having private health insurance were the factors most commonly associated with accessing non-opioid treatments.

Conclusions Patients on long-term opioid therapy report using multiple types of pain treatments. High rates of CAM use are concerning given limited evidence of efficacy for some therapies and the low-income status of most people with CNCP. Financial and insurance barriers highlight the importance of considering how different types of treatments are paid for and subsidised.

What is known about the topic? Given concerns regarding long-term efficacy, adverse side-effects and risk of misuse and dependence, prescribing guidelines recommend caution in prescribing pharmaceutical opioids in cases of CNCP, typically advising a multidisciplinary approach to treatment. There is a range of evidence supporting different (non-drug) treatment approaches for CNCP to reduce pain severity and increase functioning. However, little is known about the non-opioid treatments used among those with CNCP and the demographic and clinical characteristics that may be associated with the use of different types of treatments. Understanding the use of non-drug therapy among people with CNCP is crucial given the potential to improve pain control for these patients.

What does this paper add? The present study found that a wide range of non-opioid treatments was accessed by the study sample, both before and after commencing opioids, indicating that in this sample opioids were not the sole strategy used for pain management. The most common treatment (other than opioids) was CAM, reported by two-fifths of the sample. Having private health insurance was associated with increased use of non-opioid treatments for pain, highlighting the importance of considering how treatments are paid for and potential financial barriers to effective treatments.

What are the implications for practitioners? Patients’ beliefs and financial barriers may affect the uptake of different treatments. Many patients may be using complementary and alternative approaches with limited evidence to support their use, highlighting the need for clinicians to discuss with patients the range of prescribed and non-prescribed treatments they are accessing and to help them understand the benefits and risks of treatments that have not been tested sufficiently, or have inconsistent evidence, as to their efficacy in improving pain outcomes.

Additional keywords: acupuncture, barriers, chiropractor, complementary and alternative medicines.


References

[1]  Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder R. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014; 73 968–74.
The global burden of low back pain: estimates from the Global Burden of Disease 2010 study.Crossref | GoogleScholarGoogle Scholar | 24665116PubMed |

[2]  Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380 2163–96.
Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Crossref | GoogleScholarGoogle Scholar | 23245607PubMed |

[3]  Beubler E, Jaksch W, Devulder J, Le Poloin B, Bo Honsen O, Meynadier J, Muller-Schwefe G, Zenz M, Mac Sullivan R, O’Brien T, Eisenberg E, Mercodante S, Ventafriddo V, Varrossi G, Vielvoye-Kerkmeer A, Zylicz B, Breivik H, Krajnik M, Lopez JC, Puig M, Rhodin A, Borgeat A, Collett B, Hanna M, Hunt T, Simpson K. The white paper on opioids and pain: a pan-European challenge. The European white paper on the use of opioids in chronic pain management. J Pain Palliat Care Pharmacother 2006; 20 79–87.

[4]  Access Economics. The high price of pain: the economic impact of persistent pain in Australia. Sydney: MBF Foundation; 2007.

[5]  Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, Woolf A, Vos T, Buchbinder R. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012; 64 2028–37.
A systematic review of the global prevalence of low back pain.Crossref | GoogleScholarGoogle Scholar | 22231424PubMed |

[6]  Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev 2010; 1 CD006605
| 20091598PubMed |

[7]  Michna E, Cheng WY, Korves C, Birnbaum H, Andrews R, Zhou Z, Joshi AV, Schaaf D, Mardekian J, Sheng M. Systematic literature review and meta-analysis of the efficacy and safety of prescription opioids, including abuse-deterrent formulations, in non-cancer pain management. Pain Med 2014; 15 79–92.
Systematic literature review and meta-analysis of the efficacy and safety of prescription opioids, including abuse-deterrent formulations, in non-cancer pain management.Crossref | GoogleScholarGoogle Scholar | 24112715PubMed |

[8]  Gomez C, Vega-Quiroga S, Bermejo-Pareja F, Medrano MJ, Louis ED, Benito-Leon J. Polypharmacy in the elderly: a marker of increased risk of mortality in a population-based prospective study (NEDICES). Gerontology 2015; 61 301–9.
Polypharmacy in the elderly: a marker of increased risk of mortality in a population-based prospective study (NEDICES).Crossref | GoogleScholarGoogle Scholar | 25502492PubMed |

[9]  Williams ACDC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2012; 11 CD007407
Psychological therapies for the management of chronic pain (excluding headache) in adults.Crossref | GoogleScholarGoogle Scholar |

[10]  Bernardy K, Klose P, Busch Angela J, Choy Ernest HS, Häuser W. Cognitive behavioural therapies for fibromyalgia. Cochrane Database Syst Rev 2013; 9 CD009796
Cognitive behavioural therapies for fibromyalgia.Crossref | GoogleScholarGoogle Scholar | 24018611PubMed |

[11]  Schonstein E, Kenny DT, Keating J, Koes BW. Work conditioning, work hardening and functional restoration for workers with back and neck pain. Cochrane Database Syst Rev 2003; 1 CD001822
| 12535416PubMed |

[12]  Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992; 49 221–30.
Efficacy of multidisciplinary pain treatment centers: a meta-analytic review.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK38zgtFyhsQ%3D%3D&md5=47d6281338208aed600f264a12aecc2cCAS | 1535122PubMed |

[13]  Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001; 322 1511–16.
Multidisciplinary rehabilitation for chronic low back pain: systematic review.Crossref | GoogleScholarGoogle Scholar | 11420271PubMed |

[14]  van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000; 25 2784–96.
Exercise therapy for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3M%2FkvVKgsQ%3D%3D&md5=737f7efd552db6893184a1f93ef40aefCAS | 11064524PubMed |

[15]  Haetzman M, Elliott A, Smith B, Hannaford P, Chambers W. Chronic pain and the use of conventional and alternative therapy. Fam Pract 2003; 20 147–54.
Chronic pain and the use of conventional and alternative therapy.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3s3gsVOgsw%3D%3D&md5=0db106d9a6f8976341e9478b85ba84d0CAS | 12651788PubMed |

[16]  Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh BB. Is acupuncture effective for the treatment of chronic pain? A systematic review. Pain 2000; 86 217–25.
Is acupuncture effective for the treatment of chronic pain? A systematic review.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c3nsVSlsA%3D%3D&md5=5e3f7ec1116da22d9bcc6f94b75b4254CAS | 10812251PubMed |

[17]  McEachrane-Gross F, Liebschutz J, Berlowitz D. Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: a cross-sectional survey. BMC Complement Altern Med 2006; 6 34
Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: a cross-sectional survey.Crossref | GoogleScholarGoogle Scholar | 17026768PubMed |

[18]  Fleming S, Rabago D, Mundt M, Fleming M. CAM therapies among primary care patients using opioid therapy for chronic pain. BMC Complement Altern Med 2007; 7 15
CAM therapies among primary care patients using opioid therapy for chronic pain.Crossref | GoogleScholarGoogle Scholar | 17506893PubMed |

[19]  Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ 2006; 174 1589–94.
Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects.Crossref | GoogleScholarGoogle Scholar | 16717269PubMed |

[20]  Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O’Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10 113–30.
Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD1MXhtlCgsb0%3D&md5=0fbb5bd1022ee6834126614151d88a3fCAS | 19187889PubMed |

[21]  Campbell G, Mattick R, Bruno R, Larance B, Nielsen S, Cohen M, Lintzeris N, Shand F, Hall WD, Hoban B, Kehler C, Farrell M, Degenhardt L. Cohort protocol: the Pain and Opioids IN Treatment (POINT) study. BMC Pharmacol Toxicol 2014; 15
Cohort protocol: the Pain and Opioids IN Treatment (POINT) study.Crossref | GoogleScholarGoogle Scholar | 24646721PubMed |

[22]  Therapeutic Goods Administration. Standard for the uniform scheduling of medicines and poisons (SUSMP). Canberra: Australia Government; 2013.

[23]  Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, Kerns RD, Stucki G, Allen RR, Bellamy N, Carr DB, Chandler J, Cowan P, Dionne R, Galer BS, Hertz S, Jadad AR, Kramer LD, Manning DC, Martin S, McCormick CG, McDermott MP, McGrath P, Quessy S, Rappaport BA, Robbins W, Robinson JP, Rothman M, Royal MA, Simon L, Stauffer JW, Stein W, Tollett J, Wernicke J, Witter J. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005; 113 9–19.
Core outcome measures for chronic pain clinical trials: IMMPACT recommendations.Crossref | GoogleScholarGoogle Scholar | 15621359PubMed |

[24]  Australian Bureau Statistics (ABS). Statistical geography volume 1: Australian standard geographical classification (ASGC). Canberra: ABS; 2006.

[25]  Cleeland C. The brief pain inventory (BPI). Houston; 1991.

[26]  Nicholas MK. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain 2007; 11 153–63.
The pain self-efficacy questionnaire: taking pain into account.Crossref | GoogleScholarGoogle Scholar | 16446108PubMed |

[27]  Nicholas MK, Asghari A, Blyth FM. What do the numbers mean? Normative data in chronic pain measures. Pain 2008; 134 158–73.
What do the numbers mean? Normative data in chronic pain measures.Crossref | GoogleScholarGoogle Scholar | 17532138PubMed |

[28]  Coughlan GM, Ridout KL, Williams AC, Richardson PH. Attrition from a pain management programme. Br J Clin Psychol 1995; 34 471–9.
Attrition from a pain management programme.Crossref | GoogleScholarGoogle Scholar | 8845785PubMed |

[29]  Ware JE, Kosinksi MMA, Keller SD. How to score the SF-12 physical and mental health summary scales. 2nd edn. Boston: The Health Institute, New England Medical Centre; 1995.

[30]  Sanderson K,, Andrews G. The SF-12 in the Australian population: cross-validation of item selection. Aust N Z J Public Health 2002; 26 343–5.
The SF-12 in the Australian population: cross-validation of item selection.Crossref | GoogleScholarGoogle Scholar |

[31]  Glajchen M. Chronic pain: treatment barriers and strategies for clinical practice. J Am Board Fam Pract 2001; 14 211–18.
| 1:STN:280:DC%2BD3M3lsFOksg%3D%3D&md5=dcb6e6f039aa2fa5e23967e92dd76fb6CAS | 11355054PubMed |

[32]  Innovation New South Wales Agency for Clinical Innovation. Complementary and alternative medicine (CAM). 2014. Available from: http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0018/212823/Pain-and-CAM-Therapy.pdf [verified 15 December 2014].

[33]  Nielsen S, Degenhardt L, Hoban B, Gisev N. Comparing opioids: a guide to estimating oral morphine equivalents (OME) in research. Technical Report No. 329. Sydney: National Drug and Alcohol Research Centre, UNSW Australia; 2014.

[34]  Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, et al American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2 – guidance. Pain Physician 2012; 15 S67–116.
| 22786449PubMed |

[35]  Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychol Health 1999; 14 1–24.
The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication.Crossref | GoogleScholarGoogle Scholar |

[36]  Sullivan MD, Von Korff M, Banta-Green C, Merrill JO, Saunders K. Problems and concerns of patients receiving chronic opioid therapy for chronic non-cancer pain. Pain 2010; 149 345–53.
Problems and concerns of patients receiving chronic opioid therapy for chronic non-cancer pain.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3cXlt1Smtrg%3D&md5=2db08576623b09f34f78fff6453e43eeCAS | 20334974PubMed |

[37]  Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004; 343 1–19.
Complementary and alternative medicine use among adults: United States, 2002.Crossref | GoogleScholarGoogle Scholar | 15188733PubMed |

[38]  Xue CC, Zhang AL, Lin V, Da Costa C, Story DF. Complementary and alternative medicine use in Australia: a national population-based survey. J Altern Complement Med 2007; 13 643–50.
Complementary and alternative medicine use in Australia: a national population-based survey.Crossref | GoogleScholarGoogle Scholar | 17718647PubMed |

[39]  Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med 2001; 9 2–11.
Use and expenditure on complementary medicine in England: a population based survey.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3M7msFGmtQ%3D%3D&md5=7e7e2c4d5667215fa5f9992fd3526a72CAS | 11264963PubMed |

[40]  Simmonds MJ, Finley EP, Vale S, Pugh MJ, Turner BJ. A qualitative study of veterans on long-term opioid analgesics: barriers and facilitators to multimodality pain management. Pain Med 2015; 16 726–32.
A qualitative study of veterans on long-term opioid analgesics: barriers and facilitators to multimodality pain management.Crossref | GoogleScholarGoogle Scholar | 25528887PubMed |

[41]  Zedler B, Xie L, Wang L, Joyce A, Vick C, Kariburyo F, Rajan P, Baser O, Murrelle L. Risk factors for serious prescription opioid-related toxicity or overdose among veterans health administration patients. Pain Med 2014; 15 1911–29.
Risk factors for serious prescription opioid-related toxicity or overdose among veterans health administration patients.Crossref | GoogleScholarGoogle Scholar | 24931395PubMed |

[42]  Campbell G, Nielsen S, Bruno R, Lintzeris N, Cohen M, Hall W, Larance B, Mattick RP, Degenhardt L. The Pain and Opioids IN Treatment (POINT) study: characteristics of a cohort using opioids to manage chronic non-cancer pain. Pain 2015; 156 231–42.
The Pain and Opioids IN Treatment (POINT) study: characteristics of a cohort using opioids to manage chronic non-cancer pain.Crossref | GoogleScholarGoogle Scholar | 25599444PubMed |

[43]  Slaunwhite AK. The role of gender and income in predicting barriers to mental health care in Canada. Community Ment Health J 2015; 51 621–7.
The role of gender and income in predicting barriers to mental health care in Canada.Crossref | GoogleScholarGoogle Scholar | 25563485PubMed |