The high price of pain: the economic impact of persistent pain in Australia - November 2007

While every effort has been made to ensure the accuracy of this document, the uncertain nature of economic data, forecasting and analysis means that Access Economics Pty Limited is unable to make any warranties in relation to the information contained herein. Access Economics Pty Limited, its employees and agents disclaim liability for any loss or damage which may arise as a consequence of any person relying on the information contained in this document.

1.1 Overview ............................................................................................................................. 1

1.2 Cross-cutting methodological issues ................................................................................... 1

2.1 Definition and grading .......................................................................................................... 7

2.2 Prevalence and severity in Australia ....................................................................................11

2.3 Causes of chronic pain ......................................................................................................18

2.4 Effect of chronic pain .........................................................................................................23

2.5 Managing chronic pain .......................................................................................................27

3.1 Methodology .......................................................................................................................30

3.2 Health expenditure in 2007 ................................................................................................30

4.1 Productivity losses .............................................................................................................34

4.2 Carer costs .........................................................................................................................37

4.3 Costs of aids and modifications .................................................................................... .....39

4.4 Welfare and income support ...................................................................................... ........41

4.5 Deadweight losses .............................................................................................................42

4.6 Summary of other (non-health) financial costs .....................................................   .............44

5.1 Methodology – valuing life and health ......................................................  .........................45

5.2 Burden of disease due to chronic pain .....................................................  .........................49

7.1 Comparisons ......................................................................................................................55

7.2 Cost effective interventions ................................................................................................58

7.3 Strategic directions and challenges ...................................................................................61

Figure 1-1: Incidence and Prevalence Approaches to Measurement of Annual Costs ......... 2

Figure 2-1: How Chronic Pain Can Become a Problem .......................................................... 10

Figure 2-2: Prevalence of Chronic Pain by Age and Gender (NSW Health Survey, %) ......... 12

Figure 2-3: Prevalence of Chronic Pain by Age and Gender (NSA Pain Study, %) ............... 13

Figure 2-4: Severity of Chronic Pain (%) .............................................................................. 13

Figure 2-5: Prevalence of Chronic Pain, 2007 ...................................................................... 15

Figure 2-6: Projected Prevalence of Chronic Pain by Gender ............................................... 17

Figure 3-1: Chronic Pain, Total Health Expenditure by Age and Gender, 2007 ($M) .......... 32

Figure 3-2: Distribution of Health Expenditure by Who Pays ............................................ .... 32

Figure 3-3: Chronic Pain, Health System Costs by Type of Cost, 2007 (%) .......................... 33

Figure 4-1: Chronic Pain, Employment Rates, Full and Part Time (%) .................................. 35

Figure 4-2: Mobility Aids Used by People With and Without Chronic Pain, 2003 .................. 39

Figure 4-3: Self-Care Aids Used by People With and Without Chronic Pain, 2003 ............... 40

Figure 4-4: DWL of Taxation .........................................................................................        ....... 43

Figure 5-1: Loss of Wellbeing Due to Chronic Pain (DALYs), by Age and Gender, 2007 ...... 50

Figure 6-1: Total Costs of Chronic Pain by Type, 2007......................................................... 53

Figure 6-2: Total Costs of Chronic Pain by Bearer, 2007 ...................................................... 53

Figure 6-3: Financial Costs of Chronic Pain by Bearer, 2007................................................ 54

Figure 7-1: Prevalence Comparisons – Chronic Pain and Other Conditions, 2005 ............... 55

Figure 7-2: Health Expenditure Comparisons, Chronic Pain and Other Conditions,

2000-01 ($ Million) ..................................................                     ........................................... 56

Figure 7-3: BoD In 2003, DALYs (‘000) ................................................................................ 57

Table 1-1: Schema for Cost Classification .............................................................................. 5

Table 2-1: Prevalence of Chronic Pain, by Duration (%) ....................................................... 14

Table 2-2: Baseline Prevalence Rates by Age and Gender (%) ............................................ 14

Table 2-3: Chronic Pain by Age and Gender, Projected Prevalence to 2050 ........................ 16

Table 2-4: Chronic Pain by Severity, Projected Prevalence to 2050 ..................................... 17

Table 2-5: Chronic Pain by Duration, Projected Prevalence to 2050 .................................... 18

Table 2-6: Preceding Events of Chronic Pain (NSA Pain Study) ........................................... 19

Table 2-9: Standardised Mental Health Score of 60 Or Morea.............................................. 22

Table 2-10: Lost Work Days and Lost Work Day Equivalents (Over a Six-Month Period) ..... 24

Table 2-11: Rating of Reduced Ability to Work Due to Pain (Over a 6-Month Period) ........... 24

Table 2-12: Annual Number and Cost of Lost Workday Equivalents Due to Chronic

Pain in Australia ........................................                         ......................................................... 25

Table 3-1: Allocated Health System Costs For Chronic Pain, 2007 ...................................... 31

Table 3-2: Chronic Pain, Total Health Expenditure, 2007 ..................................................... 31

Table 4-1: Lost Earnings and Taxation Due to Chronic Pain, 2007 ....................................... 36

Table 4-2: Carers of People With and Without Chronic Pain, 2003 ....................................... 38

Table 4-3: Chronic Pain, Aids and Equipment Prices, Estimated Product Life and Total

Costs, 2007 ........................................................................................................ 41

Table 4-4: Summary of Other (Non-Health) Financial Costs of Chronic Pain, 2007 .............. 44

Table 5-1: International Estimates of VSL, Various Years .................................................... 48

Table 5-2: Estimated Years of Healthy Life Lost Due to Disability (YLD) .............................. 49

Table 5-3: Net Cost of Lost Wellbeing, $ Million, 2007.......................................................... 51

Table 6-1: Chronic Pain Cost Summary, 2007 ...................................................................... 52

Table 7-1: Total Cost Comparisons ($ Billion) ...................................................................... 58

ABS Australian Bureau of Statistics

AF Attributable Fraction

AIHW Australian Institute for Health and Welfare

AWE Average Weekly Earnings

BoD burden of disease

CATI Computer-Assisted Telephone Interviewing

CPG Chronic Pain Grade

DALY Disability Adjusted Life Year

DSP Disability Support Pension

DWL deadweight loss

IASP International Association for the Study of Pain

IDDS implanted drug delivery systems

MPC Multidisciplinary Pain Clinic

MRR Mortality rate ratio

NHPAs National Health Priority Areas

NHS National Health Survey

NOHSC National Occupational Health and Safety Commission

NA NewStart Allowance

NSA Northern Sydney Area

NSW New South Wales

OOH out of hospital

OR odds ratio

PPP purchasing power parity

QALY Quality Adjusted Life Year

SA Sickness Allowance

SDAC Survey of Disability, Ageing and Carers

SES socioeconomic status

SMR standardised mortality ratio

VSL/VSLY Value of a Statistical Life (Year)

WHO World Health Organization

YLD Years of healthy life Lost due to Disability

YLL Years of Life Lost due to premature mortality

of two or more courses of action.

of a distortion to the equilibrium (society preferred) level of output and prices. DWL occurs

when some people could be made better off without others being made worse off. Common

causes are monopoly pricing, externalities, taxes or subsidies.

among two or more explanatory variables in a regression model. This makes it difficult to

separate the effects of them on the dependent variable.

use real resources eg. taxation revenues or welfare transfers.

This report was commissioned by the MBF Foundation in collaboration with the University of Sydney Pain Management Research Institute. Access Economics would particularly like to acknowledge the role of Dr Fiona Blyth, head of the Pain Epidemiology Unit, University of Sydney Pain Management Research Institute.

Access Economics would like to acknowledge with appreciation the comments, prior research and expert input from the following:

Dr Fiona Blyth University of Sydney Pain Management Research Institute  Royal North Shore Hospital, Sydney

Professor Michael Cousins University of Sydney Pain Management Research Institute Royal North Shore Hospital, Sydney

Dr Carolyn Arnold Caulfield Pain Management & Research Centre, Melbourne Associate

Professor Stephen Gibson Director Clinical Research, National Ageing Research Institute, Melbourne

Dr Stan Goldstein MBF Foundation, Sydney

Dr Roger Goucke Head, Department of Pain Management Sir Charles Gairdner Hospital, Perth

Associate Professor Christopher Maher Faculty of Health Sciences, University of Sydney

Associate Professor Michael Nicholas University of Sydney Pain Management Research Institute Royal North Shore Hospital, Sydney

This report was commissioned by the MBF Foundation in collaboration with the University of Sydney Pain Management Research Institute to estimate the economic impact of chronic (or persistent) pain in Australia in 2007.

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Males

Females

Source: Based on New South Wales (NSW) Health Department (1999) and Blyth et al (2001).

Chronic pain has a substantial economic impact on society, reflecting both its prevalence, and the broad and significant impacts on people who experience it and those caring for them.

Not only does a person living with chronic pain have an impacted quality of life, but those who would otherwise be economically productive often have reduced productivity as an outcome. This, as well as the relationship between chronic pain and socioeconomic disadvantage, makes it an important public health concern in Australia.

Note: BoD – means burden of disease; DWL – means deadweight losses.

The largest share of chronic pain costs is borne by the individuals with chronic pain themselves who, principally due to the large BoD (burden of disease) costs, bear 55% of total costs; 22% of total costs are borne by the Federal Government, due primarily to their share of health system and productivity costs. Employers bear 5%, State Governments 5%, family and friends bear 3%, while the remaining 10% is borne by society.

In 2005, the most recent year for which comparable prevalence data on all diseases are available, chronic pain prevalence was comparable or higher than a number of National Health Priority Areas (NHPAs).  NHPA conditions include cardiovascular disease, cancer, musculoskeletal diseases, injuries, mental disorders, asthma and diabetes.

It should be noted that chronic pain, in addition to being a condition in its own right, is also an important component of NHPA conditions, for example cancer, musculoskeletal diseases and injuries.

0 2,000 4,000 6,000 8,000 10,000 12,000

Infectious & parasitic

Blood & blood forming organs

Neoplasms*

Genito-urinary system

Diabetes melitus*

Skin & subcutaneous tissue

Nervous system

Asthma*

Mental & behavioural*

Hearing loss

Chronic pain

Cardiovascular*

Musculoskeletal*

Visual disorders

Prevalence (thousands of people).

* National health priorities.

Source: Access Economics based on the Australian Bureau of Statistics (ABS) National Health Survey (NHS) 2004-05.

Note: Chronic pain, in addition to being a condition in its own right, is also an important component of NHPA conditions, for example cancer, musculoskeletal diseases and injuries.

Allocated health expenditure on chronic pain was estimated at around $4.4 billion in 2000-01 – the most recent year for which there are comparable disease health expenditure data. This was third only to cardiovascular diseases and musculoskeletal conditions among the NHPAs, while noting the overlap between costs of chronic pain and its underlying causes.

0 1,000 2,000 3,000 4,000 5,000 6,000

Asthma

Diabetes mellitus

Stroke

Depression

Ischaemic heart disease

Cancer

Mental disorders

Other Cardiovascular conditions

Injuries

Chronic pain

Musculoskeletal conditions

Cardiovascular diseases

Source: Access Economics based on the Australian Institute of Health and Welfare - AIHW (2005).

Note: Chronic pain, in addition to being a condition in its own right, is also an important component of NHPA conditions, for

example cancer, musculoskeletal diseases and injuries.

It is important to recognise that for many people, pain is not managed optimally, so that there is broad scope for reducing the economic and social impacts as they currently stand. There is a growing emphasis on developing multidisciplinary management strategies for chronic conditions such as chronic pain. Chronic pain currently imposes very substantial costs on the health care system. The term ‘effective’ needs to be defined for chronic pain – it refers to minimising the impact of persisting pain on a person’s lifestyle (quality of life), and reducing use of health services.

There are a number of areas where data are non-existent or data quality could be improved.

Chronic pain can be best managed in a collaborative and multidisciplinary fashion. Improved outcomes will require appropriately trained health professionals to assess and treat the broad range of problems in people with chronic pain.

Access Economics was commissioned by the MBF Foundation in collaboration with the University of Sydney Pain Management Research Institute to estimate the economic impact of chronic pain in Australia in 2007.

Chronic pain is defined as pain experienced every day for three months or more in the previous six months.

The report covers the following:

Specific methodologies relevant to each section are presented in the various chapters. The remainder of this chapter covers methodological issues common across the report.

All costs are expressed as present values relative to 2007.

Note that Figure 1-1 also defines the lifetime costs of chronic pain for each person, as

follows.

This report reviews the main conditions that cause chronic pain. It then estimates Attributable Fractions (AFs) for the proportion of cases under each condition where the person experiences chronic pain due to that condition. AFs are the proportion of a health condition (eg. its prevalence, mortality, disease burden or dollar costs) that is caused by – or aetiologically attributable to – a particular risk factor, after controlling for other potentially confounding factors. AFs are useful in understanding the extent to which the prevalence – and hence costs – of various conditions can be attributed to their risk factors, such as chronic pain.

For example, if 50% of people who have musculoskeletal diseases have chronic pain due to the musculoskeletal disease in a given year, then 50% of the cost of musculoskeletal diseases can be attributed to chronic pain. Repeating this calculation for the other causes of chronic pain could provide an estimate of the total health system costs, which could then be adjusted for changes in prevalence and health inflation to provide an estimate of health expenditures due to chronic pain for the year 2007.

However, even the best estimates used for the AF of chronic pain contain an amount of uncertainty. Other explanatory factors may have been inadequately controlled in source studies or may be associated with chronic pain, such as occupational factors (including injury), lifestyle, age and gender. Statistical problems in regression analysis (such as multi-collinearity) may be encountered, reflecting the complex inter-relationships between pain and other factors.

Conceptual issues relating to the classification of costs include the following.

There are three types of costs associated with chronic pain and its downstream impacts.

Different costs of diseases are borne by different individuals or sectors of society. Clearly the individual suffering chronic pain bears costs, but so do employers, government, friends and family, co-workers, charities, community groups and other members of society.

It is important to understand how the costs are shared in order to make informed decisions regarding interventions. While the person with chronic pain will usually be the most severely affected party, other family members and society (more broadly) also face costs as a result of chronic pain. From the employer’s perspective, depending on the impact of chronic pain, work loss or absenteeism may lead to costs such as higher wages (ie, accessing skilled replacement short term labour) or alternatively lost production, idle assets and other non-wage costs. Employers might also face costs such as rehiring, retraining and workers’ compensation.

While it may be convenient to think of these costs as being purely borne by the employer, in reality they may eventually be passed on to end consumers in the form of higher prices for goods and services. Similarly, for the costs associated with the health system and community services, although the Federal and State/Territory governments meet a large component of this cost, taxpayers (society) are the ultimate source of funds. However, for the purpose of this analysis, a ‘who writes the cheque’ approach is adopted, falling short of delving into second round or longer term dynamic impacts.

Society bears both the resource cost of providing services to people with chronic pain, and also the ‘deadweight’ losses (or reduced economic efficiency) associated with the need to raise additional taxation to fund the provision of services and income support.

Typically the groups who bear costs and pay or receive transfer payments are:

Classifying costs by type and allocating them by who bears the costs enables a framework for analysis (Table 1-1). the household

Costs by type of service (and prevalence in 2001)

People with chronic pain*, governments and society

Lost productivity from temporary absenteeism People with chronic pain, employer and governments#

Lost management productivity Employers and governments#

Long term lower employment rates

People with chronic pain and governments#

Includes premature retirement

Premature death People with chronic pain and governments#

Loss of productive capacity

Additional search and hiring replacement Employers Incurred when prematurely leave job

Includes both paid and unpaid work

DWL Society Relate to transfers from

taxation, welfare etc

Various, as able to be

measured, but tend to be

relatively small

Governments, people

with chronic pain,

Friends and family and

society,

Aids, modifications,

travel, accommodation,

respite/ palliative care,

funeral costs etc

BoD (YLLs, YLDs, DALYs). People with chronic pain*

The net value of BoD should exclude other costs borne by the individual to avoid double counting

* Friends/family may also bear loss of wellbeing, health costs and lower living standards as a result of chronic pain; however, care is needed to assess the extent to which these are measurable, additional (to avoid double counting) and not follow-on impacts. For example, a spouse may pay a medical bill and children may share in lower household income when the chronic pain sufferer’s work hours are reduced – but as this is simply redistribution within family income it is not measured here.

Moreover, if a family carer develops depression or a musculoskeletal disorder, it would be necessary to estimate the aetiological fraction attributable to chronic pain, allowing for other possible contributing factors.

# Where earnings are lost, so is taxation revenue and frequently also there are other transfers, such as welfare payments for disability/sickness/caring etc, so Governments share the burden.

There are essentially two ways of estimating each type of cost:

It is generally more desirable to use top-down national datasets in order to derive national cost estimates, to ensure that the whole is not greater or less than the sum of the parts. On the other hand, it is often difficult to obtain top-down estimates. In this report, the top-down approach is applicable to health system and BoD costs and the bottom-up approach applies in other cases.

The main limitations of the data are in relation to timeliness, comparability and objectivity.

Chronic pain is a common condition that has a substantial economic impact on society due to its prevalence and its various impacts on people who suffer from it and those caring for them.

The apparent relationship between chronic pain and socioeconomic disadvantage makes it an important public health concern in Australia. There is a growing emphasis on developing multidisciplinary management strategies for chronic illnesses such as chronic pain. However, there are relatively few Australian data on the prevalence of chronic pain and its impact on individuals and health services and the broader community.

The International Association for the Study of Pain (IASP) have defined pain as: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (IASP, 1986).

Linton (2005) added that pain is “expressed in behaviour”.

The key points about this definition are:

a) Pain is always subjective (there are no objective measures of it);

b) Pain is an experience, with sensory and emotional aspects;

c) The relationship between tissue damage and pain is variable, so the size of an injury can be a poor guide as to how much pain someone is in. The signals the body sends from an injury site are referred to as nociceptive signals. These signals only become experienced as pain when they reach the conscious brain, and the person interprets them as pain. That interpretation is influenced by many factors, including past experience, beliefs, and the situation; and

d) Pain is expressed in behaviour - that is how we communicate it to others and an important effect of pain is on behaviour.

Common features associated with chronic pain are:

Reasons for the persistence of pain beyond the acute stage are often difficult to pinpoint and computerised tomography or magnetic resonance imaging scans are not reliable predictors of pain and disability. While some ongoing pain is due to clear nerve damage (eg. spinal cord or spinal nerve injury), in many cases no identifiable cause can account for the persistence of pain.

Current research indicates that a more likely explanation lies in the development of changes in function within the central nervous system and this may be demonstrated by the processes called central sensitisation, whereby previously non-noxious activities or stimuli come to aggravate pain and other associated symptoms.

Unless there is some form of ongoing stimulation, nociceptive pain usually (but not always) settles with healing. The persistence of pain beyond three months after injury may be due to identified pathology, but for many chronic pain conditions there may be no clear cause as the original injury may have healed. It is now recognised that growth factors and other pain related chemical factors released by injury may trigger an ongoing sensitisation of pain fibres.

In the case of chronic low back pain, for example, many authorities claim that no specific basis has been found for up to 80-85% of cases (eg. Airaksinen et al, 2005; Waddell and Burton, 2005). These figures are disputed by some researchers, but it remains the case that most chronic back pain that is not due to a specific injury (with clear pathology) has no lasting, curative treatment, and even when there is clear pathology there is often no curative treatment (Bogduk, 2004; Goucke, 2003).

Recent evidence indicates that changes in the way the nervous system (which mediates pain responses) responds to injury and persisting pain may explain a substantial proportion of chronic pain syndromes.

Some of the changes in nerve functions thought to explain the abnormal sensations and sensitisation found in neuropathic pain include reduced descending inhibition in the CNS (the intact CNS normally inhibits a proportion of noxious signals coming from the periphery, but if this system is impaired more signals get through to the brain and more pain and other sensations can be experienced) (Siddall and Cousins, 2004).

While the more specific features associated with neuropathic pain are not evident in all people with chronic pain following injury, similar neural mechanisms or changes at a CNS level are thought to underpin most chronic pain conditions, especially where there is no obvious, ongoing pathology.

Although this model has developed over time, with new findings resulting in changes to the previous concepts of chronic pain, each version shares common features (Flor and Hermann, 2004; Turk, 2002b).

The main characteristic of these models is that they attempt to account for the experience of pain and its impact in terms of an interaction between the three main factors. Thus biological changes (eg. injury) can lead to psychological effects (eg. pain) which, in turn, can affect the body through mechanisms like avoidance of activity (which may lead to deconditioning, as well as depression).

The figure below provides a summary of how persisting pain can become a greater problem than it needs to be.

REDUCED ACTIVITY

UNHELPFUL BELIEFS & THOUGHTS

REPEATED TREATMENT FAILURES

LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS

LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS

CHRONIC PAIN

PHYSICAL DETERIORATION

(eg. muscle wasting, joint stiffness)

FEELINGS OF DEPRESSION, HELPLESSNESS, IRRITABILITY SIDE EFFECTS

(eg. stomach problems lethargy, constipation) M K Nicholas PhD Pain Management & Research Centre Royal Nor th Shore Hospital St Leonards NSW 2065 AUSTRALIA

EXCESSIVE SUFFERING

This model of pain has important implications for treatment and management. Simply stated, the model predicts that if biological, personal and/or environmental factors appear to be contributing to an emerging chronic pain condition (or syndrome), as many as possible of these facets should be addressed in any intervention to prevent the pain from becoming unnecessarily disabling. Failure to do so risks creating a major long term health problem with all its likely complications and costs (Turk, 2002b; Loeser, 1996; Linton, 2002; Main, 2002).

Grade I, low disability-low intensity;

Grade II, low disability-high intensity;

Grade III, high disability-moderately limiting; and

Grade IV, high disability-severely limiting.

The CPG has been validated by various international studies and found to be an acceptable, valid and reliable instrument for assessing the presence and severity of chronic pain (Penny et al, 1999).

There are relatively few data in Australia on the prevalence of chronic pain. The best method of measuring community prevalence is through well-designed representative surveys of populations, using a consistent definition of chronic pain. Two of the most representative studies of chronic pain in the general adult Australian population include the state-wide 1997 New South Wales (NSW) Health Survey and the Northern Sydney Area (NSA) Pain Study of 1998. Both surveys used the IASP definition of chronic pain as ‘pain experienced every day for three months or more in the previous six months’ prior to the survey being conducted.

The sample of the survey consisted of around 1,000 respondents from each of NSW’s 17 geographically defined health administration areas (NSW Health Areas). To be eligible, respondents had to be aged 16 years and over, live in a private residence with access to a phone, and speak English or one of six other community languages (Blyth et al, 2001).

Computer-assisted telephone interviewing (CATI) was used to collect data. A two-stage stratified sample design was used, consisting of (1) simple random sampling of household telephone numbers within strata (NSW Health Areas); and (2) simple random sampling of a household resident aged 16 years and over from each selected household (NSW Health Department, 1999). Interviews were completed by 17,543 respondents with an overall response rate of 70.8% (Health Area range 63.9–79.4%). The demographic profile of the sample is comparable to that of NSW as a whole (Blyth et al, 2001).

Some 20% of females and 17.1% of males reported experiencing chronic pain (Figure 2-2).

For males, prevalence peaked at 27.0% in the 65-69 year age group and was generally higher in men aged 55 to 69 years. For females, prevalence peaked at 31.0% in the oldest age group (80-84 years) and was consistently higher after the age of 50 years compared to younger age groups. Indeed, prevalence was less than 10% only in males aged 16-19 years.

However, it should be noted that the oldest and youngest age groups contained relatively small numbers of respondents (Blyth et al, 2001).

0%

5%

10%

15%

20%

25%

30%

35%

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 All ages

Males

Females

Source: Based on NSW Health Department (1999) and Blyth et al (2001).

Survey. Data were collected by CATI using random digit dialling methods within the NSA, an

urban geographical area with a base population exceeding 700,000 (ABS, 1997).

Once contact with a household was made, participants were chosen by randomly sampling

from eligible household members (18 years of age or more, and speaking English as their

primary language) using CATI technology. No substitution of household members was

permitted. Data collection occurred between July and September, 1998.

In addition to being consistent with the IASP definition of chronicity, in this survey chronic

pain severity was also measured using the CPG outlined above. More details on the design

and sample characteristics are available elsewhere (Blyth et al, 2003a).

Chronic pain was reported by 474 of the 2,092 respondents (293 women and 181 men),

giving an age-and gender-adjusted prevalence of chronic pain of 22.1% - a similar (albeit

slightly higher) outcome compared to the 1997 NSW Health survey data. Women had a

higher prevalence than men (24.1% versus 19.9%). Prevalence was highest in the 70 years

and over age group for men at 26% and the 60–69 year age group for women at 36% (Figure

2-3) (Blyth et al, 2003a).

0%

5%

10%

15%

20%

25%

30%

35%

40%

18-29 30-39 40-49 50-59 60-69 70+ All ages

Males

Females

Source: Blyth et al (2003a).

While most respondents experienced the least disabling type of chronic pain (CPG I at 39%),

high levels of pain related disability (CPGs III and IV) still occurred in 27% of the respondents

(Figure 2-4). Pain was most commonly experienced in the back (45% of those with chronic

pain), followed by the leg (42%), shoulder (29%), arm (22%) and neck (20%), with a

substantial proportion of respondents having pain in multiple sites.

0%

10%

20%

30%

40%

50%

Least severe to most severe pain

Source: NSA Pain Study, Blyth et al (2003a).

Most chronic pain lasted between one and ten years for both males (45.7%) and females

(55.4%). However, 27.9% of respondents reported chronic pain with duration of more than

10 years, and a significant proportion of pain persisted beyond 20 years (14.9% for males

and an even greater 18.2% for females).

3-6 months 9.5% 6.0% 7.5%

7-12 months 13.9% 13.2% 13.5%

1-10 years 45.7% 55.4% 51.2%

11-20 years 16.0% 7.3% 11.1%

>20 years 14.9% 18.2% 16.8%

Source: NSA Pain Study, Blyth et al (2003a).

Table 2-2 provides estimates of chronic pain (by age and gender) that are used in this report.

They are based on the finding of the NSW Health Survey as this is a more representative

study compared to the NSA Pain Study – having a larger sample size and including people

from broader backgrounds such as individuals from rural areas and non-English speakers.

Overall, the prevalence of chronic pain is higher in women (20.0%) than in men (17.1%);

prevalence was higher for women in every age group except ages 35-44. Given that the

NSW Health Survey does not include data on chronic pain in children, chronic pain is

conservatively assumed to be zero for children aged 0-14 years.

15-19 8.0% 11.6%

20-24 11.7% 13.8%

25-29 10.7% 11.9%

30-34 14.0% 13.1%

35-39 16.6% 16.3%

40-44 18.2% 16.1%

45-49 19.6% 23.7%

50-54 19.1% 27.6%

55-59 26.0% 29.3%

60-64 22.8% 28.0%

65-69 27.0% 29.3%

70-74 20.5% 27.2%

75-79 21.0% 26.0%

80-84 18.7% 31.0%

85-89 18.7% 20.0%

90+ 18.7% 20.0%

Source: Based NSW Health Department (1999) and Blyth et al (2001).

Note: ‘total’ percentages are relative to the population aged 15 years and older.

Figure 2-5 shows the estimated prevalence of chronic pain for 2007, calculated using the

prevalence rates from Table 2-2 and figures for the Australian population for 2007 (from the

Access Economics Demographic Model based on ABS demographic data).

estimated to experience chronic pain.

pain (190,426), while the 55-59 age group has the highest number of men with chronic

pain (166,368).

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Males

Females

Source: Based on NSW Health Department (1999) and Blyth et al (2001).

Table 2-3 outlines the projected prevalence of chronic pain in the total population on the

basis of demographic ageing only, not taking into account any changes in age-gender

prevalence rates in the future.

(from around 3.2 million Australians in 2007 to 5.0 million by 2050).

16.5% to 18.4% (noting that these proportions are relative to the population of all ages,

so are lower than the totals in Table 2-2 due to the assumption of zero prevalence

among children aged under 15 years).

15-19 59,135 60,694 58,337 58,750 63,026 63,749

20-29 165,598 174,705 187,250 182,896 187,405 197,372

30-39 227,887 228,407 256,802 275,429 269,466 275,263

40-49 284,048 286,460 292,873 328,972 351,722 345,012

50-59 296,402 308,163 340,888 350,283 391,958 421,430

60-69 231,406 261,527 325,652 362,144 374,851 423,475

70+ 172,216 187,400 276,177 381,882 474,230 541,801

% of males 13.9% 14.1% 14.4% 14.9% 15.2% 15.4%

% of total prevalence 45.4% 45.4% 45.5% 45.5% 45.5% 45.8%

15-19 81,826 83,667 80,296 80,809 86,666 87,632

20-29 183,686 193,882 206,924 201,706 206,626 217,310

30-39 220,931 219,318 241,395 258,103 251,846 256,826

40-49 302,168 304,438 307,196 335,723 359,543 351,123

50-59 379,081 397,263 432,867 436,310 482,008 513,584

60-69 267,628 304,791 389,871 426,593 431,649 478,570

70+ 292,980 310,153 423,538 583,422 709,987 783,040

% of females 16.5% 16.8% 17.3% 17.8% 18.2% 18.4%

% of total prevalence 54.6% 54.6% 54.5% 54.5% 54.5% 54.2%

15-19 140,961 144,361 138,633 139,559 149,692 151,382

20-29 349,284 368,588 394,173 384,602 394,031 414,682

30-39 448,818 447,726 498,196 533,532 521,312 532,089

40-49 586,217 590,899 600,069 664,695 711,266 696,135

50-59 675,483 705,426 773,755 786,593 873,966 935,013

60-69 499,034 566,318 715,522 788,737 806,499 902,045

70+ 465,196 497,553 699,715 965,304 1,184,217 1,324,841

% of persons 15.2% 15.4% 16.1% 16.4% 16.7% 16.9%

Source: Based on NSW Health Department (1999) and Blyth et al (2001).

Note: ‘total’ percentages are relative to the Australian population (all ages).

The above results exclude children (aged 0-14).

Table 2-3 further highlights the projected growth in chronic pain prevalence from 15.2% of

the population in 2007 to 16.9% by 2050.

compared to 2.3 million males (Figure 2-6).

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

2007 2010 2020 2030 2040 2050

Males Females

Source: Based on NSW Health Department (1999) and Blyth et al (2001).

Note that the ‘kink’ in the chart reflects that the first period is three years while other periods are a decade.

Projected chronic pain severity is reported in Table 2-4. Again this only looks at the effect of

demographic ageing on the severity of chronic pain, and excludes any treatments or

interventions that might affect chronic pain severity.

type of chronic pain (either Grade I with around 1.9 million people by 2050 and Grade II

with 1.7 million people).

respondents or around 1.3 million people by 2050.

Grade I 1,218,522 1,278,535 1,470,725 1,641,264 1,786,779 1,908,132

Grade II 1,091,922 1,145,700 1,317,922 1,470,743 1,601,139 1,709,885

Grade III 443,099 464,922 534,809 596,823 649,738 693,866

Grade IV 411,449 431,713 496,608 554,193 603,328 644,304

Source: Based on NSW Health Department (1999) and Blyth et al (2001).

Table 2-5 outlines projections of chronic pain duration to 2050, highlighting that pain with

duration of one to ten years is the most common, and increasing from around 1.6 million in

2007 to 2.5 million in 2050.

period of more than 20 years (around 0.5 million in 2007, rising to around 0.8 million by

2050 with population ageing).

3-6 months 136,486 143,199 165,108 184,334 200,702 215,470

7-12 months 199,700 209,523 241,579 269,710 293,659 315,266

1-10 years 656,568 688,862 794,256 886,743 965,485 1,036,523

11-20 years 229,871 241,177 278,076 310,457 338,025 362,896

>20 years 214,067 224,596 258,959 289,113 314,786 337,947

3-6 months 103,698 108,811 124,925 139,360 151,700 201,606

7-12 months 228,136 239,384 274,835 306,592 333,739 362,891

1-10 years 956,614 1,003,779 1,152,435 1,285,596 1,399,428 1,374,955

11-20 years 126,166 132,386 151,992 169,555 184,568 298,377

>20 years 313,686 329,152 377,899 421,564 458,891 450,254

3-6 months 240,184 252,010 290,033 323,694 352,402 417,076

7-12 months 427,836 448,906 516,414 576,301 627,398 678,158

1-10 years 1,613,183 1,692,641 1,946,690 2,172,339 2,364,913 2,411,478

11-20 years 356,037 373,564 430,069 480,012 522,593 661,274

>20 years 527,754 553,749 636,857 710,677 773,677 788,202

Source: Based on NSW Health Department (1999) and Blyth et al (2001).

There are many underlying causes of chronic pain, although it is not possible to always

determine the precise cause of the pain. Chronic pain may occur due to the persistent

stimulation of nociceptors in areas of ongoing tissue damage, for example, chronic pain due

to osteoarthritis. Frequently, however, chronic pain persists long after the tissue damage that

initially triggered its onset has resolved, and in some individuals, chronic pain can continue

without ongoing tissue damage or preceding injury that can be detected with currently

available diagnostic technology.

These common chronic pain syndromes include: chronic low back pain, headache,

myofascial pain syndrome, fibromyalgia, neuropathic pain, phantom limb pain, central pain

syndromes, arthritis, cancer, post-herpetic neuralgia, and chronic post-surgical pain.

Knowledge about the underlying pathophysiology of many of these disorders is limited

(Ashburn et al, 1999). The NSA Pain Study identified that chronic pain was most commonly

experienced in the back (45% of those with chronic pain), followed by the leg (42%),

shoulder (29%), arm (22%) and neck (20%), with some respondents having pain in multiple

sites (Blyth et al, 2003a).

The NSA Pain Study further identified injury as the major cause of chronic pain, followed by a

health problem (Table 2-6). The most common type of injury was sports injury (13% of

people with chronic pain), which was particularly common in men with chronic pain (21%).

Work-related accidents and conditions were the nominated cause in 14% of people. of those

with chronic pain, 35% reported having a diagnosed cause from a doctor, most commonly

arthritis (9%). When reported diagnoses were classified according to World Health

Organization (WHO) ICD-10 categories, diseases of the musculoskeletal system and

connective tissues (M00–M99) were most common with 26%. However, it can also be seen

that a third of respondents could not identify a preceding event (injury or health problem) that

had caused chronic pain (Blyth et al, 2003a).

Injury 38

Sports injury 13

Work accident 4

Car accident 8

Home accident 7

Other injury 6

Health problem 29

Illness 11

Work-related (not involving an accident) 9

Other health problem 8

No clear reason 32

Don’t know 1

Source: Blyth et al (2003a).

Chronic pain particularly affects older people, females, and those with lower socioeconomic

status (SES) and poorer health status. Chronic pain has the potential to have a pervasive

impact on people who experience it, and may profoundly affect their mood, physical

functioning and social relationships. Individuals with chronic pain can also experience

depression, sleep disturbance, fatigue and reduced overall physical effectiveness.

Andersson et al (1993) found that dysfunctional chronic pain was more prevalent in

respondents with low SES. Von Korff et al (1990) demonstrated associations between

increased levels of pain disability and unemployment, lower levels of educational attainment

and lower levels of household income. However, chronic pain is a significant problem across

all levels of socioeconomic status.

other risk factors.

The survey found that chronic pain was associated with age, with the average age of chronic

pain respondents higher compared to respondents with no chronic pain, and a higher rate of

women with chronic pain (Table 2-7). This finding has also been confirmed by the NSA Pain

Study (see Section 2.2 above).

Chronic pain was associated with lower SES. NSW Health Survey respondents with the

highest educational level (university or other post-school qualification) or with private health

insurance cover were significantly less likely to have chronic pain (Table 2-7).

People with chronic pain were much more likely to be receiving a government pension or

benefit compared to respondents without chronic pain, and were more than twice as likely to

receive disability benefits. Respondents receiving a pension or benefit were 70% more likely

to have chronic pain compared to respondents not receiving a pension or benefit.

In addition, there were strong associations between receiving a disability benefit or

unemployment benefit and having chronic pain. Being unemployed due to health reasons

accounted for 7.6% of chronic pain respondents but only 1.3% of respondents without

chronic pain, an almost six-fold difference.

Significantly, fewer chronic pain respondents were in full time or part time employment

(30.9% people with chronic pain vs. 42.8% for individuals without chronic pain). After

adjustment for age, sex and comorbidity differences, being unemployed for health reasons

was still strongly associated with having chronic pain (adjusted odds ratio (OR) = 6.41), as

was being unemployed per se (adjusted OR = 1.70) (Blyth et al, 2001).

No pain Chronic painb Adjusted

(n = 13,899) (n = 3598) Odds ratioc

% (n) % (n) (95% CI)

Age

Male 41.8 years 47.4 years

Female 42.6 years 50.1 years

Gender

Male 43.4 (6027) 40.5 (1458)***

Female 56.6 (7872) 59.5 (2140)***

Pension or benefit type

Disability benefit 8.3 (341) 17.4 (318)*** 3.89 (3.15-4.79)***f

Unemployment benefit 11.2 (444) 9.4 (147)* 1.99 (1.57-2.52)***f

Employment status

Employed Full-time 42.8 (5718) 30.9 (1047)***

Employed Part-time 12.9 (1867) 11.5 (405)* 1.09 (0.92-1.28)g

Unemployed 4.2 (6100) 5.0 (205)* 1.70 (1.37-2.11)***g

Unemployed/Health reasons 1.3 (197) 7.6 (295)*** 6.41 (4.97-8.28)***g

a * Significant at p=0.05%; ** Significant at p=0.01%; *** Significant at p=0.001%.

b Comparison group for significance tests is no pain.

c Mean (95% confidence interval) adjusted for sex, age and comorbidity.

d Reference group, did not complete secondary schooling.

e Reference group, no private health insurance cover.

f Reference group, not receiving a pension or benefit.

g Reference group, employed full-time.

Source: Based on NSW Health Department (1999) and Blyth et al (2001).

The NSW Health Survey found that individuals with chronic pain were far more likely to rate

their health as poor compared to the no pain group. of people with chronic pain where the

pain caused interference with daily activities, 15.7% rated their health as poor compared with

1.4% for individuals without chronic pain (Table 2-8).

Respondents with poor self-rated health status were significantly more likely to report having

chronic pain compared to those who rated their health more positively (adjusted OR = 7:24

(5.87±8.92). Within the chronic pain group, poor self-rated health was associated with a fivefold

increase in the likelihood of having interference with daily activities due to chronic pain

(adjusted OR = 5:01 (3.53±7.11) (Blyth et al, 2001).

No pain Chronic pain & Chronic pain &

% (n) % (n) % (n)

Excellent 21.6 (3013) 12.5 (145)*** 6.4 (144)***

Very good 39.4 (5434) 32.6 (400)*** 21.0 (484)***

Good 28.2 (3868) 33.5 (427)** 29.3 (667)***

Fair 9.3 (1347) 17.4 (228)*** 27.5 (659)**

Poor 1.4 (235) 4.0 (59)*** 15.7 (384)***

a ** Significant at p=1%; *** Significant at p=0.1%.

b Comparison group for significance tests is no pain.

c Comparison group for significance tests is chronic pain with no interference.

Source: Based on NSW Health Department (1999) and Blyth et al (2001).

These findings are consistent with international studies which have found that chronic pain is

independently related to low self-rated health in the general population (for example,

Mantyselka et al, 2003).

The NSW Health Survey found that there was a significant increase in psychological distress

in both males and females reporting chronic pain which interfered with their daily activities.

The survey measured psychosocial distress using a ten-item questionnaire on the level of

anxiety and depressive symptoms experienced by respondents in the preceding four weeks.

For example, respondents were asked: `In the last four weeks, how often did you feel that

everything was an effort?' For each item, there is a five-point adjective scale related to the

amount of time during the preceding four weeks that the respondent experienced the

particular problem (from `all of the time' to `none of the time'). Raw scores ranging

between 0 to 50 were converted to a T-score with a mean of 50 and a standard deviation of

10. Scores of 60 or more (representing one standard deviation above the mean) have been

found to correspond to high levels of psychological distress using other established

measures (NSW Health Department, 1999).

The survey also found that having chronic pain alone was associated with increased levels of

distress for females but not for males (Table 2-9). Respondents with standardised mental

health scores of 60 or more were three times more likely to report having chronic pain

compared to respondents with lower scores. Within the group reporting chronic pain, having

standardised mental health scores of 60 or more was significantly associated with the

presence of interference with activities due to pain (Blyth et al, 2001).

No pain Chronic pain & Chronic pain &

no interference b interference c

% (n) % (n) % (n)

Males 8.8 (511) 8.9 (46) 30.9 (284)***

Females 12.4 (967) 17.9(131)** 33.3 (472)***

a ** Significant at p=1%; *** Significant at p=0.1%.

b Comparison group for significance tests is no pain.

c Comparison group for significance tests is chronic pain with no interference.

Source: Based on NSW Health Department (1999) and Blyth et al (2001).

The findings from the NSW Health Survey on psychological distress are consistent with other

research that suggests there is a link between chronic pain and mental conditions such as

distress and depression (Clarke et al, 2005).

to major depressive symptoms.

depression scale scores and site-specific pain conditions (Von Korff et al, 1988) across

different populations.

Other studies also corroborate that there is an association between experiencing interference

with daily activities due to chronic pain and increased levels of psychological distress (eg.

Rudy et al, 1988).

Chronic pain, especially when it has a long duration, may be associated with an increased

risk of mortality. However, there are relatively few data available regarding the association

between chronic pain and mortality.

over eight to nine years showed an association between reported widespread pain and

mortality in cancer. The study found that 1,005 (15.3%) participants had widespread

pain, 3,176 (48.3%) had regional pain, and 2,388 (36.4%) experienced no pain. During

follow up, mortality was higher in people with regional chronic pain (mortality rate ratio

(MRR) 1.21, 95% confidence interval 1.01 to 1.44) and widespread chronic pain

(MRR 1.31, confidence interval 1.05 to 1.65) than in those who reported no pain. The

excess mortality among people with regional and widespread chronic pain was largely

related to deaths from cancer (MRR 1.55 (1.09 to 2.19) for regional pain and MRR of

2.07 (1.37 to 3.13) for widespread pain). There were also more deaths from causes

other than disease (for example, accidents, suicide, violence) among people with

widespread pain (MRR 5.21, 0.94 to 28.78). The excess cancer mortality remained

after exclusion of people in whom cancer had been diagnosed before the initial survey

and after adjustment for potential confounding factors. The explanations of these

findings were not clear; however, the effects of stress and pain on the immune system

2 Somatisation is when physical symptoms develop through stress or emotional problems. Somatisation disorder

is diagnosed when a person has experienced multiple physical complaints and symptoms over a long period of

time. These symptoms cannot be identified or explained through medical examinations or tests.

were suggested as possible explanations for the higher mortality (Macfarlane et al,

2001).

mortality was higher in the study respondents who reported chronic widespread pain at

the outset. During the 12-year period of the study, 23 out of 214 individuals died (or

10.7%): 5 from the 73 individuals without chronic pain at the start of the study (or

6.8%), 5 from the 71 individuals with neck–shoulder pain (or 7.0%) and 13 out of 70

individuals from the widespread pain group (a higher 18.6%), a significant difference

between the groups. Median age at death was 72 (range 48–83) and 12 individuals out

of 23 were females. Only one of the deceased individuals in the group with widespread

pain had a known malignancy at the time of the initial survey. However the causes of

the other deaths were not examined (Andersson, 2004).

an average of around five years also found excess mortality (standardised mortality

ratio (SMR) 1.3; 95% CI, 0.9–1.7). Among the females, who formed most of the cohort,

there was excess mortality from suicide (SMR 9.1; 95% CI, 3.3–19.8), liver disease

(4.9; 95% CI 1.3–12.5) and cerebrovascular disease (SMR 3.8; 95% CI 1.4–8.2)

(Macfarlane, 2005).

an excess risk for dying (SMR 1.45; 95% CI, 1.19–1.86), using population mortality

rates as a comparison. The causes of death in excess were accidental deaths (SMR

4.5; 95% CI, 2.0–10.1), infection (SMR 4.5; 95% CI, 1.7–11.9) and pneumonia (SMR

3.3; 95% CI, 1.2–8.8). Mortality was also higher in those who initially had higher levels

of disability (Wolfe et al, 1999 in Macfarlane, 2005).

The research available suggests that people with chronic widespread pain may experience

overall increased mortality, with the excess in the order of around 30%. However, these

studies relate mainly to one type of chronic pain – chronic widespread pain – which is

reported by around 10% to 13% of adults with any chronic pain (Macfarlane, 2005).

While it would be possible to attribute costs of premature mortality in this analysis, the overall

view of the authors, in the interests of conservatism, is that the evidence on premature death

is not strong enough to include at this stage in cost estimates, but this aspect should remain

as part of a future research agenda.

Chronic pain imposes a large socioeconomic burden for those who suffer from it, and for

society at whole. This is evident through the impact of chronic pain on work performance, on

health service utilisation and on wellbeing.

Chronic pain can adversely affect work performance through absence from work due to the

pain (‘absenteeism’) as well as affecting the ability to work effectively when at work

(‘presenteeism’). Absenteeism is measured by looking at the number of work days missed by

people with chronic pain. Presenteeism can be estimated by multiplying the number of days

worked with chronic pain by the percentage reduction in effectiveness on days worked with

pain. For example, four days worked with pain with a 50% decrease in work effectiveness

would result in an estimate of two reduced effectiveness work days.

The NSA Pain Study found that chronic pain had an impact on work performance, through

individuals working while suffering from chronic pain. Working with pain was more common

(on average 83.8 days over a six month period) than lost work days due to pain (4.5 days)

among chronic pain participants in full time or part time employment. When both lost work

days and reduced effectiveness work days were summed, an average of 16.4 lost work day

equivalents occurred in a six month period, approximately three times the average number of

lost work days (Table 2-10) (Blyth et al, 2003a). However, the standard deviation in these

estimates is high.

Work impact variables Distributional characteristics a

Mean (sd) Median

Work days with pain 83.8 (55.0) days 80 days

Lost work days 4.5 (13.2) days 0 days

Percent reduced effectiveness 14.2% (20.5)% 3%

Reduced effectiveness days 11.9 b

Lost work day equivalents 16.4 (28.4) days 3.3 days

a Results to be interpreted with caution given high standard deviation.

b Derived from work days with pain and percent reduced effectiveness.

Source: NSA Pain Study, Blyth et al (2003a).

Notably, a substantial proportion of individuals were able to work with pain, with 68.5%

reporting more than 30 days of working with chronic pain in the previous six months. Similar

results were reported for both males and females. Most participants (60% of males and 54%

of females) reported some degree of reduction in their work effectiveness due to their pain.

Interestingly, 38.9% of those who had worked with pain stated that they experienced no

reduction in their ability to perform their work (Table 2-11). This suggests that the complete

relief of chronic pain may not be an essential therapeutic target where return to work is the

desired outcome (Blyth et al, 2003a).

Rating a N %

0 103 38.7

1–5 135 53.3

6–10 13 4.9

Do not know 10 3.0

a Rating from 0 (no reduction) to 10 (unable to do any work at all);

converted to percentages to estimate reduced effectiveness.

Source: NSA Pain Study, Blyth et al (2003a).

The cost to Australian employers in terms of absenteeism and reduced work effectiveness

was estimated by van Leeuwen et al (2006). They found that there were 9.9 million days

spent away from work due to chronic pain, equating to an estimated cost of $1.4 billion per

year. When reduced effectiveness work days were added, the total number of lost workday

equivalents rose to 36.5 million, amounting to an estimated cost of $5.1 billion per year (van

Leeuwen et al, 2006).

more reduced effectiveness workdays, with the total number of lost workday

equivalents estimated as 24.5 million days for males and 12.0 million for females. This

may reflect greater labour force participation and greater exposure to the types of jobs

with a higher incidence of work-related conditions causing chronic pain.

respectively (Table 2-12).

It should be noted that the estimation focussed specifically on work absence and reduction in

work effectiveness due to chronic pain. It did not include other costs such as those attributed

to administering sick leave or workers compensation claims, workplace modifications or

treatment costs.

Age Number of days Number of lost Cost of days absent Cost of lost workday

Males

20–24 0.5 2.0 77.9 (76.6-79.1) 291.7 (287.0-296.2)

25–34 1.4 5.1 197.3 (194.1-200.3) 738.7 (726.9-750.1)

35–44 1.9 7.2 277.6 (273.2–281.9) 1,039.8 (1,023.2–1,055.8)

45–54 1.7 6.5 249.8 (245.8–253.7) 935.5 (920.6–949.9)

55–64 1.0 3.6 137.7 (135.5–139.8) 515.6 (507.3–523.5)

Subtotal 6.5 24.5 940.3 (925.3–954.8) 3,521.2 (3,456.1–3,575.5)

Females

20–24 0.4 1.3 46.7 (45.8–47.7) 168.7 (165.5–172.1)

25–34 0.6 2.3 85.0 (83.4–86.7) 307.0 (301.0–313.0)

35–44 0.9 3.2 115.5 (113.2–117.8) 416.9 (408.8–425.1)

45–54 1.1 3.9 142.0 (139.2–144.8) 512.5 (502.5–522.6)

55–64 0.4 1.3 47.9 (47.0–48.9) 173.0 (169.6–176.4)

Subtotal 3.3 12.0 437.2 (428.7–445.8) 1578.1 (1547.4–1609.2)

a Lost workday equivalents = days absent + reduced-effectiveness workdays.

b 95% Confidence Interval (CI) presented in brackets.

Source: Van Leeuwen et al, (2006).

The implications are that, while the extent of the impact of reduced work effectiveness on

days worked with pain on productivity is uncertain due to the large standard deviation, it has

the potential to account for a large part of lost productivity costs associated with chronic pain.

Further, interventions that target working despite pain, together with other support such as

job flexibility, could significantly reduce lost productivity costs due to chronic pain (Van

Leeuwen et al, 2006).

Chronic pain has also been associated with increased litigation, mainly work related.

The NSA Pain Study found that 8.7% of people with chronic pain identified that their pain

problem had been the subject of a claim for damages or a legal case. Males were twice as

likely to report involvement in litigation compared with females (12.0% versus 6.2%).

followed by accident compensation claims (24.2%). Males were more likely to report

workers compensation claims (55.0%) compared to females (46.1%). In contrast,

females were more likely to be involved in third party accident compensation claims.

chronic pain were usually more disabled, utilised more health services, home help and

medication than non-litigants with chronic pain (Blyth et al, 2003b).

Molloy et al (1999) reported that between 1991-92 and 1995-96, pain related legal payments

in NSW increased three times to $120 million. In 1995-96, pain related claims comprised

12.6% of legal payments for back injury, 7.6% of payments for medical treatment, and 3% of

payments for physiotherapy and chiropractic treatment.

reports of pain are limiting the ability of sufferers to return to work. This could help

avoid unnecessary suffering, increasing disability, and associated legal and other costs

(Molloy et al, 1999).

Chronic pain is generally associated with higher consumption of health care services. There

are several reasons for this, including the significant global impact of chronic pain on every

day functioning and quality of life, and repeated treatment that may result in the use of

monotherapies of limited value.

severity (measured variously by pain intensity, number of pain sites and the CPG) was

positively correlated with health care use (Eriksen et al, 2004, Andersson et al, 1999;

Chrubasik et al, 1998).

The NSW Health Survey examined whether having chronic pain and higher levels of pain

related disability would be associated with greater use of health services. Health care was

assessed across primary care, emergency departments and hospital admissions. The survey

found that individuals with chronic pain were more likely to access health services and also

more likely to be frequent users when accessing health services (NSW Health Department,

1999). The results are presented in detail in Table 2-13.

Health service use category Chronic pain status N Meanb (SD) Range

Overnight hospital No chronic pain 13,897 0.18 (0.01) 0–23

admissions last 12 months Chronic pain—no interference 1,259 0.19 (0.02) 0–14

Chronic pain—little /moderate interference 1,061 0.22 (0.03) 0–7

Chronic pain—lots /extreme interference 1,272 0.46c (0.04) 0–20

Emergency department (ED) No chronic pain 13,898 0.17 (0.01) 0–60

visits last 12 months Chronic pain—no interference 1,260 0.20 (0.02) 0–10

Chronic pain—little /moderate interference 1,061 0.25 (0.03) 0–9

Chronic pain—lots /extreme interference 1,270 0.85d (0.30) 0–150

GP visits last 12 months No chronic pain 13,882 4.81 (0.08) 0–156

Chronic pain—no interference 1,260 5.69(0.23) 0–200

Chronic pain—little /moderate interference 1,060 6.88 (0.30) 0–104

Chronic pain—lots /extreme interference 1,264 10.72 c (0.52) 0–156

GP visits last 2 weeks No chronic pain 12,042 0.40 (0.01) 0–15

Chronic pain—no interference 1,149 0.40 (0.03) 0–12

Chronic pain—little /moderate interference 1,004 0.45(0.04) 0–14

Chronic pain—lots /extreme interference 1,210 0.59e (0.04) 0–15

a Results should be interpreted with caution given high standard deviation. Interference refers to interference

with daily activities.

b Adjusted for age, gender, self-rated health, distress, comorbidity.

c Significant at p =5% compared with pain—little /moderate interference group .

d Significant at p =5% compared with pain—little /moderate interference group or the pain—no interference group .

e Significant at p =5% compared with the pain—no interference group .

Note: Data relates to overall use of healthcare, and not just healthcare use related to chronic pain.

Source: Based on NSW Health Department (1999) and Blyth et al (2006).

The average number of visits or admissions was higher for individuals experiencing chronic

pain (with or without interference with daily activities) and rose with increasing levels of

interference with daily activities due to chronic pain.

admissions was between one and a half and five times higher in the group with most

pain related disability.

with most pain related disability reported more: primary care visits in the last two weeks

and last 12 months (adjusted average number of visits 0.59 vs 0.40 and 10.72 vs 4.81);

hospital admissions (0.46 vs 0.18); and emergency department visits (0.85 vs 0.17).

Experiencing chronic pain alone, or having chronic pain with any level of activity interference

predicted more health care use (after adjusting for age, gender, self-rated health,

psychological distress, comorbidity and access to care). Higher levels of pain related

disability predicted health care use more than other pain status variables. There was a strong

association between pain related disability and greater use of services (Blyth et al, 2004).

It is important to recognise that as new evidence emerges, the role of different treatments

can change. Nevertheless, there are key principles that should underpin strategic directions

for the organisation and delivery of effective chronic pain management services, as follows.

from acute to chronic pain are most likely to reduce the disability and economic costs

associated with chronic pain. Assessment is critical as soon as someone is not back to

normal functioning as expected after initial treatment.

with early referral for multi-disciplinary pain assessment (if required) is needed.

single treatment is likely to be enough. If more than one treatment provider is involved,

a coordinated (and consistent) treatment plan is essential.

consensus by experts in the field) is that a collaborative and multidisciplinary approach

to management is likely to help most.

services offered. As a result it is suggested that a term like ‘multidisciplinary pain clinic’

(MPC) may be preferred as it conveys a sense of multiple services.

assessment/treatment of patients with complex and disabling pain, the training of all

health professionals in this work, research into persisting pain, and public education

about chronic pain and its management.

level (by different health care providers working collaboratively, as required).

of functional gains. Long-term management of patients assessed in MPCs will involve

coordination with primary practitioners.

obstacles to progress. Simply addressing pain severity alone is unlikely to be sufficient

in promoting functional goals.

and treating the broad range of problems experienced by those with chronic pain is

required.

evaluation of treatments.

of people, treatments in such cases are typically aimed at minimising the symptoms

and enabling the patient to regain (and maintain) as much normal activity as possible.

must identify and target as many of the factors contributing to the ongoing pain,

disability and barriers for successful return to functioning as possible.

nervous system changes associated with chronic pain. This has already resulted in

some experimental drugs that will target the ‘disease process’ rather than the

symptomatic treatment of pain (refs 34,35,14a). This raises the future possibility of

curative treatment for at least some chronic pain conditions.

As the available evidence on cost effectiveness is sparse (see next section), a brief overview

of the current state of knowledge about effective interventions for chronic pain is necessary,

to demonstrate the range of treatments available, and to highlight the comparatively small

empirical base of cost effectiveness information.

It should be acknowledged that there are not multiple (or any in some cases) randomised

controlled trials on every treatment or combination of treatments for every type of chronic

pain. Research into chronic pain treatments and their implementation has been limited.

However, it is possible to draw some conclusions from available evidence and experience. In

all cases the characteristics of people being treated must be considered to avoid generalising

from some very selected samples to all patients with chronic pain.

The current evidence for common pain treatments is summarised in Appendix 1. This does

not apply to the treatment of specific conditions, such as cancer or arthritis, but rather where

the pain has been present daily for more than three months since onset and the focus of

treatments is the relief or control of pain as well as limiting its impact on the person’s

functional activities (reducing disability).

The implications of this evidence are summarised below.

1. Treatment should be supported by evidence (in the literature) for effects in relevant

areas (eg. pain, function, mood).

2. Given that more than one treatment is likely to be needed for many patients

(eg. spinal cord stimulation plus pain program), they should be complementary. If one

treatment is aimed at pain relief as a sole outcome while the others are aimed at

functional gains there may be a conflict for the patient. Treatment providers should

consider how possible conflicts will be overcome or avoided (simply expecting

function to improve with pain reduction is unlikely to be enough if the person is fearful

of pain or re-injury).

3. If there is more than one treatment provider, agreement on a coordinated (and

consistent) treatment plan is essential.

4. Chronic pain is a chronic condition, so any treatment plan must have provision for

maintenance of gains (and arrangements for dealing with relapses).

In cancer patients with persistent pain, there are major differences in treatment options

compared to non-cancer pain, because of limited life expectancies and clear-cut underlying

causes of pain. Thus, the use of pharmacological treatments, including opioids, is frequently

appropriate. In addition, some interventional treatments, such as neurolytic coeliac plexus

block and spinal drug delivery are highly effective (e.g. Smith et al, 2002).

This report reviews the main conditions that cause chronic pain as identified by the NSA Pain

Study. It then estimates AFs for the proportion of cases under each condition where the

person experiences chronic pain due to that condition. AFs are the proportion of a health

condition (eg. its prevalence, mortality, disease burden or dollar costs) that is caused by – or

aetiologically attributable to – a particular risk factor, after controlling for other potentially

confounding factors. AFs are useful in understanding the extent to which the prevalence –

and hence costs – of various conditions can be attributed to their risk factors or underlying

conditions, in this case the proportion of chronic pain that is attributed to underlying

conditions such as injury or musculoskeletal disease.

For example, if 50% of people who have musculoskeletal diseases have chronic pain due to

the musculoskeletal disease in a given year, then 50% of the cost of musculoskeletal

diseases can be attributed to chronic pain. Repeating this calculation for the other causes of

chronic pain provides an estimate of the total health system costs, which can then be

adjusted for changes in prevalence and health inflation to provide an estimate of health

expenditures due to chronic pain for the year 2007.

The AIHW recurrent health expenditure data for 2000-01 were used as the basis for Access

Economics’ estimates for health expenditure on chronic pain in 2007. However, It is

important to note that chronic pain is not an ICD-10 (International Classification of Disease,

Tenth Revision) condition, so the health expenditure estimates attributed to chronic pain in

this analysis are not able to be summed with the costs estimated by condition by the AIHW

using the Disease Costs and Impact Study methodology, as this would result in double

counting. Rather, the costs of chronic pain can be understood conceptually as a subset of

the health system expenditures attributed to ICD-10 conditions.

The AIHW include only 87.5% of total recurrent health expenditure in their estimates of

expenditure by disease and injury, referred to as ‘allocated’ health expenditure. The

‘unallocated’ remainder includes capital expenditures, expenditure on community health

(excluding mental health), public health programs (except cancer screening), health

administration and health aids and appliances. As a result, allocated health expenditure is

factored up by 1/0.875 to obtain total health system costs.

The other factors contributing to the extrapolation to 2007 are demographic growth by age

and gender groups (increasing prevalence of chronic pain) based on ABS data, and health

cost inflation based on AIHW (2006). Health inflation measures around 3-4% per annum.

changes that have occurred over this time, Access Economics estimates that in 2007 the

allocated health system expenditure associated with chronic pain is around $6.1 billion – or

$1,930 per person with chronic pain.

3 The most recent health cost inflation release is 2005, consequently, 2005-06, and 2006-07 figures have been

estimated based on the 2000-01 to 2004-05 average.

Table 3-1 outlines the allocated health system expenditure by the underlying causes of

chronic pain.

contribute the largest share of health spending at around $2.7 billion or 43% of the total

allocated health expenditure.

Section 2.

Musculoskeletal 24.1 5,763 761,430 882

Mental health/behavioural 1.1 4,652 35,415 98

Gastrointestinal 1.0 3,496 32,464 95

Neurological 0.7 3,373 20,659 53

Infection 0.6 1,522 17,708 171

Circulatory (cardiovascular) 0.7 6,813 20,659 48

Genitourinary 0.6 2,582 17,708 82

Endocrine/hormonal 0.2 1,974 5,903 8

Respiratory 0.2 4,653 5,903 6

Source: Access Economics based on detailed causes of pain from NSA Pain Study, and health costs from AIHW (2005).

When ‘unallocated’ costs are included, health system expenditure rises to around $7.0 billion

(Table 3-2).

Source: Access Economics based on detailed causes of pain from NSA Pain Study, and health costs from AIHW (2005).

Figure 3-1 shows health expenditure by age and gender.

is on males. This reflects the higher prevalence of chronic pain in women.

0

100

200

300

400

500

600

700

800

900

1,000

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Females

Males

Source: Access Economics based on AIHW (2005) and the NSA Pain Study.

Health system costs of chronic pain (Figure 3-2) are largely borne by the Federal

government ($3.2 billion) and State and Territory governments ($1.5 billion). Individuals

contribute $1.3 billion, while society and family/friends make up the remaining $0.9 billion.

Source: Access Economics based on AIHW (2005) and the NSA Pain Study.

Note: numbers may not sum to 100% due to rounding.

Half of health system expenditure for people with chronic pain is incurred in the hospital

sector, with inpatient costs 31% of the total ($2.19 billion) and outpatients a further 19%

($1.3 billion) (Figure 3-3). Out of hospital (OOH) medical costs (GPs, OOH specialists,

pathology and imaging services) are around 15% of health costs ($1.0 billion), while allied

health and pharmaceuticals are each a little over 8% ($590 million and $570 million

respectively). Residential aged care is just under 5% of the total ($343 million), while

research and other allocated costs comprise around 1% of the total ($68 million). The

unallocated component is 12.5% of the total, by definition ($873 million).

Source: Access Economics based on AIHW (2005) and the NSA Pain Study.

Note: Total = $7.0 billion.

In addition to health system costs, chronic pain also imposes a number of other important

financial costs on society and the economy, including: productivity losses (due to work

absenteeism, loss of employment and premature death); carer costs; and deadweight

efficiency losses arising from transfer payments to people with chronic pain.

It is important to make the economic distinction between real and transfer costs.

overall capacity to produce goods and services.

use up real resources, for example, a disability support pension (DSP), or taxation

revenue.

In this report, we estimate two types of indirect costs of chronic pain.

morbidity and the associated deadweight taxation losses, and other financial costs eg.

carers, aids and home modifications for those disabled by their persistent pain.

death and loss of life quality that result from chronic pain. These are more difficult to

measure, but can be analysed in terms of the years of healthy life lost, both

quantitatively and qualitatively, known as the ’BoD’, with an imputed value of a

‘statistical’ life so as to compare these costs with financial costs of chronic pain.

Productivity losses are the cost of production that is lost when people with chronic pain are

unable to work because of the condition. They may work less than they otherwise would

(either being employed less, being absent more often or being less productive while at work)

or they may die prematurely. Access Economics adopts a human capital approach to

measurement of productivity losses in developed countries. This report draws on the

Australian estimates from the NSA Pain Study of ORs for various productivity parameters,

controlling for data quality and other confounding factors.

Chronic pain can affect a person’s ability to work. If employment rates are lower for people

with chronic pain, this loss in productivity represents a real cost to the economy.

As outlined in Table 2-7 earlier, the NSW Health Survey indicated that significantly fewer

chronic pain respondents were in full time employment (30.9% people with chronic pain

compared to 42.8% for individuals without chronic pain – a difference of 11.9%) or part time

employment (11.5% people with chronic pain compared to 12.9% for individuals without

chronic pain – a difference of 1.5%, rounded). When weighting these lower levels of

employment for people with chronic pain by the distribution of people working full and part

time in the general population (71.7% and 28.3% respectively), an 8.9% overall reduction in

employment is estimated for people with chronic pain (Figure 4-1).

0%

10%

20%

30%

40%

50%

60%

With chronic pain Without chronic pain Difference

Full time

Part time

Source: Access Economics based on NSW Health Department (1999).

Given AWE for each respective age group, the annual cost of lost earnings due

to the reduced employment is estimated at around $7.8 billion in 2007.

The NSA Pain Study found that chronic pain had an impact on work performance both

through absence from work due to the pain (‘absenteeism’) as well as affecting the ability to

work effectively when at work (‘presenteeism’). As outlined in Table 2-10 earlier, working with

pain was more common (on an average 83.8 days with a reduced work effectiveness of

14.2% over a six month period) than lost work days due to pain (4.5 days) among chronic

pain participants in full time or part time employment. However, to be conservative due to the

substantial uncertainty created by the large standard error, we have used the lower bound of

the estimate from the NSA Pain Study. In the case of reduced effectiveness days, the mean

minus the standard deviation is 83.8-55=28.8 days, which at 14.2% effectiveness equates to

4.1 workdays lost in six months or 8.2 in a twelve month period. There is no further

allowance for days absent as the mean minus the standard deviation in that case is less than

zero. The same number of days (8.2) is estimated to be lost, for those who do not work, from

their household productivity, which is valued at 30% of AWE. Further research is

recommended in this area to increase the certainty in the estimates.

Based on these parameters and the AWE of each age-gender group, Access

reduced productivity for people in paid work and $589 million in reduced

productivity at home.

Chronic pain, especially when it is widespread and with a long duration, may be associated

with an increased risk of mortality. However, there are relatively few data available regarding

the precise association between chronic pain and mortality. As outlined in Section 2.3.2

above, people with chronic widespread pain may experience overall increased mortality, with

the excess in the order of around 30%. However, chronic widespread pain is reported by only

around 10% to 13% of adults with any chronic pain. In contrast, the AIHW reports that there

is no increased risk of mortality due to chronic back pain (Begg et al, 2007). As a result, there

may be a relative risk of mortality of around 1.03 due to chronic pain, which would suggest

an estimated 976 deaths due to chronic pain in 2007 (457 males and 519 females).

However, Access Economics adopted a conservative approach in this analysis and hence

did not attributed mortality costs to chronic pain. Instead, further research is suggested to

provide a more robust estimate of the mortality risk.

Reduced earnings due to reduced workforce participation, absenteeism and premature death

will also have an effect on taxation revenue collected by the Government. As well as forgone

income (personal) taxation, there will also be a fall in indirect (consumption) tax, as those

with lower incomes spend less on the consumption of goods and services.

Personal income tax forgone is a product of the average personal income tax rate (18.3%)

and the forgone income. With chronic pain and lower income, there will be less consumption

of goods and services, with the indirect taxation rate estimated as 15.1%. These average

taxation rates are derived for 2007 from the Access Economics macroeconomic model.

Around $3.7 billion in lost potential tax revenue is estimated to be incurred in

2007, due to the reduced productivity of people with chronic pain.

Lost taxation revenue is considered a transfer payment, rather than an economic cost per se.

However, raising additional taxation revenues does impose real efficiency costs on the

1.25% of revenue raised (derived from total amounts spent and revenue raised in 2000-01,

relative to Commonwealth department running costs). Even larger DWLs arise from the

distortionary impact of taxes on workers’ work and consumption choices. These distortionary

impacts are estimated to be 27.5% of each tax dollar collected (Lattimore, 1997 and used in

Productivity Commission, 2003:6.15-6.16, with rationale). Altogether the DWL is 28.75% of

the value of the taxation forgone (Section 4.6).

productivity of people with chronic pain (Table 4-1).

Average personal income tax rate* 18.3%

Potential personal income tax lost $2.02 billion

Average indirect tax rate* 15.1%

Potential indirect tax lost $1.67 billion

total potential tax revenue lost $3.69 billion

* Source: Access Economics macroeconomic model (2007).

Welfare payments made to people who are no longer working must, in a budget-neutral

setting, also be funded by additional taxation. The DWLs associated with welfare transfers

are calculated in Section 4.6, where the nature of DWLs is explained in more detail.)

Carers are people who provide informal care to others in need of assistance or support. Most

informal carers are family or friends of the person receiving care. Carers may take time off

work to accompany people with chronic pain to medical appointments, stay with them in

hospital, or care for them at home. Carers may also take time off work to undertake many of

the unpaid tasks that the person with chronic pain would do if they did not have chronic pain

and were able to do these tasks.

Informal care is distinguished from services provided by people employed in the health and

community sectors (formal care) because the care is generally provided free of charge to the

recipient and is not regulated by the government.

While informal care is provided free of charge, it is not free in an economic sense, as time

spent caring is time that cannot be directed to other activities such as paid work, unpaid work

(such as housework or yard work) or leisure. As such, informal care is a use of economic

resources.

There are three potential methodologies that can be used to place a dollar value on the

informal care provided.

formal care sector.

Access Economics has adopted the opportunity cost method in this report as it provides the

most accurate estimate of carer costs and sufficient demographic data on providers of care

for people with chronic pain are available.

This report analyses the available epidemiological data (from Australia and overseas)

together with data from the ABS SDAC (ABS, 2003), to gain estimates of the total number of

hours of care provided to people with chronic pain in 2007, and the average unit cost of that

care.

captured in formal health sector costs. Examples include the cost of services provided to

assist with rehabilitation, mobility or independent living, the costs of aids and modifications to

the homes of people with chronic pain, and travel to health services. Estimates of these costs

for 2007 are based on investigation of the available data and literature on useage rates and

on unit costs.

Data from the 2003 SDAC sourced specifically for this report identified around, 194,000

carers who cared for people with ‘chronic or recurrent pain or discomfort’ and 208,500 carers

who cared for people without chronic pain. The age-gender distribution of these carers is

shown in Table 4-2. To allow for the people with chronic pain who would have received care

anyway (even in the absence of the pain), it is necessary to identify the ‘excess’ amount of

care provided to people with chronic pain. In total, 6.6% of people with chronic pain had a

carer compared to 1.2% of those who did not. The difference was 5.3% or 168,892 people

with chronic pain in 2007 who had a carer, who are estimated would not have had one in the

absence of the chronic pain.

15-64 years 53 1.80% 34.3 0.20% 1.60% 50,380

65+ years 30.5 1.00% 16.6 0.10% 0.90% 29,579

Total 83.5 2.80% 50.9 0.30% 2.50% 79,959

15-64 years 82.4 2.80% 124.2 0.70% 2.10% 65,068

65+ years 28.1 1.00% 33.3 0.20% 0.80% 23,883

Total 110.5 3.70% 157.5 0.90% 2.80% 88,952

15-64 years 135.4 4.60% 158.6 0.90% 3.60% 115,429

65+ years 58.6 2.00% 49.9 0.30% 1.70% 53,463

* In 2003 there were an estimated 2.953 million Australians with chronic pain, and $16.919 million Australians without.

** Multiplying the difference in the previous column by the number of people with chronic pain in 2007.

Assuming that the split between primary and non-primary carers is the same as for the

population as a whole, there were an estimated 31,183 primary and 137,727 non-primary

carers in 2007 for people with chronic pain. Based on the demographic characteristics of

carers from the SDAC data, of these carers, 15,864 and 70,065 respectively are estimated to

be employed.

SDAC data were also available for the average number of hours of care provided by primary

carers. of primary carers, 28.5% provided less than 20 hours of care per week on average,

18.4% provided between 20 and 40 hours and 44.2% provided more than 40 hours (with the

remaining 8.8% not stating the number of care hours provided). Using these data, Access

Economics conservatively calculated there was a weighted average of 26 hours of informal

care per week provided by primary carers of people with chronic pain. For non-primary

carers, an estimate of five hours per week was made, in line with previous studies

(eg. Access Economics, 2005).

chronic pain in 2007.

Chronic pain, especially in its more disabling forms, has the potential to affect a person’s

ability to conduct their daily activities and this may result in the need to acquire aids and

devices to assist them in carrying out these tasks. People with chronic pain may also need to

make modifications to their homes, such as adding handrails and ramps in order to ensure

they can safely conduct their lives.

Results from SDAC show that of those who reported chronic or recurrent pain or discomfort:

The difference in utilisation for each type of aid was calculated from the SDAC data.

Examples are provided of these differences in usage for mobility aids in Figure 4-3 and for

self-care in Figure 4-4.

2.1%

1.3%

6.2%

9.2%

3.8%

0.5%

0.9%

0.3%

1.7%

0.7%

0.4%

0.7%

2.3%

0.7%

0.1%

3.2%

3.7%

2.2%

0.2% 0.4%

0.1%

0.4% 0.2% 0.2% 0.4%

0.9%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

Canes (Sonar canes, etc)

Crutches

Walking frame

Walking stick

Wheelchair (Manual)

Wheelchair (Electric)

Scooter

Specially modified car

or car aid(s)

Braces or belts or corsets

Built-up shoe(s)

Calipers or splints

Ejector chair

Other mobility aid(s)

With chronic pain

Without chronic pain

Source: SDAC special data request.

14.1%

8.6%

6.2%

4.2%

2.1% 2.1%

7.1%

12.6%

16.5%

23.4%

33.1%

7.7%

4.4% 3.7%

2.1% 1.7% 1.1%

3.2%

6.0%

7.6%

22.4%

19.2%

0%

5%

10%

15%

20%

25%

30%

35%

Showering or bathing

Toileting

Managing incontinence

Dressing

Eating

Meal preparation

Getting into or out of a bed

or chair

Moving about the house

Moving around places away

from home

Communication

Managing health conditions

using medical aids

With chronic pain

Without chronic pain

Source: SDAC special data request.

Differences in utilisation rates were used to estimate the number of ‘excess’ aids and

modifications used by people with chronic pain, relative to people without chronic pain. Cost

estimates for various products were based on prices provided by the Independent Living

Centre NSW, the Victorian Aids and Equipment Program and previous studies undertaken by

Access Economics, inflated to 2007 prices. While some equipment and modifications require

large outlays but are depreciated over a number of years, other devices need to be replaced

more regularly. It was assumed that devices in heavy use (eating, dressing and continence

aids and batteries) need to be replaced on an annual basis, while most other devices – with

a cost range of between $32 and $213 (showering and toileting aids and most mobility aids

such as canes, crutches, walking sticks and frames) – have a lifespan of three years, and

larger expenses such as wheelchairs ($5,330) and hearing aids ($2,665) were depreciated

over five years. Home modifications ($7,995) tend to be one-off investments, so their lifespan

was assumed to be 20 years (Table 4-4).

Overall, the cost for aids and equipment for people with chronic pain was

estimated at around $331.7 million in 2007 – or $105 per person with chronic

pain.

As it is not known how much of this cost is subsidised by governments, paid for by the

person with chronic pain or their family and friends, or paid for through community programs,

the amount is allocated in four equal portions to the Federal Government, State Government,

family and friends and society/other.

Showering or bathing aids2 $91 3 $30 200,693 6,061,926

Dressing aids1 $21 1 $21 67,731 1,444,090

Toileting aids2 $85 3 $28 131,118 3,727,436

Managing incontinence1 $1,279 1 $1,279 79,174 101,285,008

Walking stick2 $32 3 $11 173,910 $1,853,981

Crutches $53 3 $18 36,551 $649,426

Walking frame1 $320 3 $107 95,512 $10,182,154

Wheelchair or scooter1 $5,330 5 $1,066 76,234 $81,269,774

Specially modified car or car

aid2

$213 3 $71 6,283 $446,527

Other mobility aids4 3 $214 116,658 $24,941,871

Communication aids

(electronic, non-electronic

and other hearing and

communication aids)3

$2,665 5 $533 29,585 $15,769,867

Home modifications (incl

structural changes, ramps,

bath modifications, doors

widened, handrails, etc)5

$7,995 20 $400 205,706 $ 82,235,340

Sources: ABS (2003);1 Victorian Aids and Equipment Program; 2 Independent Living Centre NSW; 3 Access Economics

(2006a); 4 average of mobility aids; 5 Access Economics (2006b). Note: People may use multiple devices.

Transfer payments represent a shift of resources from one economic entity to another. The

act of taxation and redistribution creates distortions and inefficiencies in the economy, so

transfers also involve real net costs to the economy.

Data regarding the number of people on income support payments was sourced from

Centrelink Australia, specially for this report. The most commonly received Centrelink work

related benefit was the DSP, which 7,399 people living with chronic pain were receiving in

June 2007. There were also 1,978 people with chronic pain receiving NewStart Allowance

(NA) and 49 people receiving Sickness Allowance (SA), due to their chronic pain.

some of these people would have ordinarily received welfare payments, which must be

netted out to estimate the additional welfare payments due to chronic pain, using a

Melbourne University study (Tseng and Wilkins, 2002) about the ‘reliance’ of the general

population (aged 15-64 years) on income support of around 12%. Factoring down the $109

The welfare payments calculated immediately above are, like taxation revenue losses, not

themselves economic costs but, rather, a financial transfer from taxpayers to the income

support recipients. The real resource cost of these transfer payments is only the associated

DWL.

DWLs refer to the costs of administering welfare pensions and raising additional taxation

revenues. Although invalid and sickness benefits and forgone taxation are transfers, not real

costs (so should not be included in the estimation of total costs) it is still worthwhile

estimating them as that helps us understand how the total costs of chronic pain are shared

between the taxpayer, the individual and other financiers.

There are two sources of lost tax revenue that result from the lower earnings – the potential

income tax forgone and the potential indirect (consumption) tax forgone. The latter is lost

because, as income falls, so does consumption of goods and services. The average

personal income tax rate used is 18.3% and the average indirect taxation rate used is 15.1%,

based on parameters for 2007 from the Access Economics macroeconomic model.

Transfer payments (Government payments/services and taxes) are not a net cost to society

as they represent a shift of consumption power from one group of individuals to another in

society. If the act of taxation did not create distortions and inefficiencies in the economy, then

transfers could be made without a net cost to society. However, through these distortions,

taxation does impose a DWL on the economy.

DWL is the loss of consumer and producer surplus, as a result of the imposition of a

distortion to the equilibrium (society preferred) level of output and prices. Taxes alter the

price and quantity of goods sold compared to what they would be if the market were not

distorted, and thus lead to some diminution in the value of trade between buyers and sellers

that would otherwise be enjoyed (Figure 4-5).

4 Based on a payment of $446.60 per fortnight for DSP; and $429.80 for NA and SA.

Price ($)

Output

Supply

Demand

Price plus Tax

Price

Taxation Revenue

Actual Quantity

Supplied

Potential Quantity

Supplied

Deadweight Loss (cost

of raising taxation

revenue)

The rate of DWL used in this report is 27.5 cents per $1 of tax revenue raised plus 1.25 cents

per $1 of tax revenue raised for Australian Taxation office administration, based on

Productivity Commission (2003) in turn derived from Lattimore (1997), ie, 28.75% overall.

The total extra tax dollars required to be collected include:

component of health system costs, with $1.36 billion of DWL);

DWL in the case of chronic pain); and

DWL).

Thus the DWL for people with chronic pain in 2007 is estimated at around $2.6

billion.

In total, the non-health related financial costs of chronic pain are estimated to be

around $15.8 billion in 2007.

Employment impacts 7,841.2

Absenteeism 3,810.5

Since Schelling’s (1968) discussion of the economics of life saving, the economic literature

and morbidity risk. Using evidence of market trade-offs between risk and money, including

numerous labour market and other studies (such as installing smoke detectors, wearing

The willingness to pay approach estimates the value of life in terms of the

amounts that individuals are prepared to pay to reduce risks to their lives. It uses

stated or revealed preferences to ascertain the value people place on reducing

risk to life and reflects the value of intangible elements such as quality of life,

health and leisure. While it overcomes the theoretical difficulties of the human

capital approach, it involves more empirical difficulties in measurement (BTE,

2000, pp20-21).

Viscusi and Aldy (2002) summarise the extensive literature in this field, most of which has

used econometric analysis to value mortality risk and the ‘hedonic wage’ by estimating

compensating differentials for on-the-job risk exposure in labour markets, in other words,

determining what dollar amount would be accepted by an individual to induce him/her to

increase the possibility of death or morbidity by a given percentage. They find the VSL

ranges between US$4 million and US$9 million with a median of US$7 million (in year 2000

US dollars), similar but marginally higher than the VSL derived from US product and housing

markets, and also marginally higher than non-US studies, although all in the same order of

magnitude. They also review a parallel literature on the implicit value of the risk of non-fatal

injuries.

A particular life may be regarded as priceless, yet relatively low implicit values

may be assigned to life because of the distinction between identified and

anonymous (or ‘statistical’) lives. When a ‘value of life’ estimate is derived, it is

not any particular person’s life that is valued, but that of an unknown or statistical

individual (Bureau of Transport and Regional Economics, 2002, p19).

Weaknesses in this approach, as with human capital, are that there can be substantial

variation between individuals. Extraneous influences in labour markets such as imperfect

information, income/wealth or power asymmetries can cause difficulty in correctly perceiving

the risk or in negotiating an acceptably higher wage.

Viscusi and Aldy (2002) include some Australian studies in their meta-analysis, notably

Kniesner and Leeth (1991) of the ABS with VSL of US2000 $4.2 million and Miller et al

(1997) of the National Occupational Health and Safety Commission (NOHSC) with quite a

high VSL of US2000$11.3m-19.1 million (Viscusi and Aldy, 2002, Table 4, pp92-93). Since

there are relatively few Australian studies, there is also the issue of converting foreign (US)

data to Australian dollars using either exchange rates or purchasing power parity (PPP) and

choosing a period.

Access Economics (2003) presents outcomes of studies from Yale University (Nordhaus,

1999) – where VSL is estimated as $US2.66m; University of Chicago (Murphy and topel,

1999) – US$5m; Cutler and Richardson (1998) – who model a common range from US$3m

to US$7m, noting a literature range of $US0.6m to $US13.5m per fatality prevented (1998

US dollars). These eminent researchers apply discount rates of 0% and 3% (favouring 3%)

to the common range to derive an equivalent of $US 75,000 to $US 150,000 for a year of life

gained.

In an attempt to overcome some of the issues in relation to placing a dollar value on a human

life, in the last decade an alternative approach to valuing human life has been derived. The

approach is non-financial, where pain, suffering and premature mortality are measured in

terms of DALYs, with 0 representing a year of perfect health and 1 representing death (the

converse of a QALY where 1 represents perfect health). This approach was developed by

WHO, the World Bank and Harvard University and provides a comprehensive assessment of

mortality and disability from diseases, injuries and risk factors in 1990, projected to 2020

(Murray and Lopez, 1996). Methods and data sources are detailed further in Murray et al

(2001).

The DALY approach has been adopted and applied in Australia by the AIHW with a separate

comprehensive application in Victoria. Mathers et al (1999) from the AIHW estimate the BoD

and injury in 1996, including separate identification of premature mortality; YLL, and

morbidity; YLD components. In any year, the disability weight of a disease (for example, 0.18

for a broken wrist) reflects a relative health state. In this example, 0.18 would represent

losing 18% of a year of healthy life because of the inflicted injury.

The DALY approach has been successful in avoiding the subjectivity of individual valuation

and is capable of overcoming the problem of comparability between individuals and between

nations, although nations have subsequently adopted variations in weighting systems. For

example, in some countries DALYs are age-weighted for older people although in Australia

the minority approach is adopted – valuing a DALY equally for people of all ages.

The main problem with the DALY approach is that it is not financial and is thus not directly

comparable with most other cost measures. In public policy making, therefore, there is

always the temptation to re-apply a financial measure conversion to ascertain the cost of an

injury or fatality or the value of a preventive health intervention. Such financial conversions

tend to utilise “willingness to pay” or risk-based labour market studies described above.

The Department of Health and Ageing (based on work by Applied Economics) adopted a

very conservative approach to this issue, placing the value of a human life year at around

A$60,000 per annum, which is lower than most international lower bounds on the estimate.

5 In round numbers, $2,000,000 = $118,000/1.05 + $118,000/(1.05)2 + … + $118,000/(1.05).40

As the citation concludes, the estimate of $60,000 per DALY is very low. The Viscusi (1993)

meta-analysis referred to reviewed 24 studies with values of a human life ranging between

$US 0.5 million and $US 16m, all in pre-1993 US dollars. Even the lowest of these converted

to 2003 Australian dollars at current exchange rates, exceeds the estimate adopted ($1m) by

nearly 25%. The BTE study tends to disregard the literature at the higher end and also

adopts a range (A$1-$1.4m) below the lower bound of the international range that it identifies

(A$1.8-$4.3m).

The rationale for adopting these very low estimates is not provided explicitly. Certainly it is in

the interests of fiscal restraint to present as low an estimate as possible.

In contrast, the majority of the literature as detailed above appears to support a higher

estimate for VSL, as presented in Table 5-1, which Access Economics believes is important

to consider in disease costing applications and decisions. The US dollar values of the lower

bound, midrange and upper bound are shown at left. The ‘average’ estimate is the average

of the range excluding the high NOHSC outlier. Equal weightings are used for each study as

the:

field after conducting literature analysis.

Where there is no low or high US dollar estimate for a study, the midrange estimate is used

to calculate the average. The midrange estimates are converted to Australian dollars at PPP

(as this is less volatile than exchange rates) of USD=0.7281AUD for 2003 as estimated by

the OECD.

6 The equivalent value of $60,000 assumes, in broad terms, 40 years of lost life and a discount rate of 5 per cent.

[Access Economics comment: More accurately the figure should be $58,278.]

7 In addition to the cited references in the text, see for example Murphy and topel’s study (1999) on the economic

value of medical research.

with a mid-range estimate of $6.5m. These estimates have conservatively not been inflated

to 2004 prices, given the uncertainty levels.

Viscusi and Aldy metaanalysis

2002

Australian: ABS 1991 4.2 5.8

NOHSC 1997 11.3 19.1

Harvard (Cutler and

Richardson) 1998

0.6 5 13.7 6.9

* Average of range excluding high NOHSC outlier, using midrange if no data; conservatively not inflated A$m conversions are at

the OECD 2003 PPP rate.

A discount rate is used to convert future income or a cost stream into the equivalent value in

today’s dollars.

Choosing an appropriate discount rate for present valuations in cost analysis is a subject of

some debate, and can vary depending on what type of future income or cost stream is being

considered. There is a substantial body of literature, which often provides conflicting advice,

on the appropriate mechanism by which costs should be discounted over time, properly

taking into account risks, inflation, positive time preference and expected productivity gains.

The absolute minimum option that one can adopt in discounting future income and costs is to

set future values in current day dollar terms on the basis of a risk free assessment about the

future (that is, assume the future flows are similar to the certain flows attaching to a long term

Government bond).

Wages should be assumed to grow in dollar terms according to best estimates for inflation

and productivity growth. In selecting discount rates for this project, we have thus settled upon

the following as the preferred approach.

5.8% pa (from recent history) as the parameter for this aspect of the discount rate (If

there were no positive time preference, people would be indifferent between having

something now or a long way off in the future, so this applies to all flows of goods and

services).

delivers 2% to 3% inflation over the course of the economic cycle. This is a realistic

longer run goal and we therefore use a value of 2.5% pa for this variable (It is important

to allow for inflation in order to derive a real (rather than nominal) rate).

8 Calculated from the non-indexed studies themselves. Converting the Access Economics average estimates from

USD to AUD at PPP would provide slightly higher estimates - $3.9 million and $10.2m, with the same midrange

estimate.

Report 2007 assumed productivity growth of 1.5% in the decade to 2010 and 1.75%

thereafter. We suggest 1.75% for the purposes of this analysis as many of the

productivity costs extend past 2010.

There are then three different real discount rates that should be applied.

5.8 - 2.5 - 1.75 = 1.55%.

5.8 - (3.2 - 1.75) - 1.75 = 2.6%.

5.8 – 2.5 = 3.3%

While there may be sensible debate about whether health services (or other costs with a high

labour component in their costs) should also deduct productivity growth from their discount

rate, we argue that these costs grow in real terms over time significantly as a result of other

factors such as new technologies and improved quality, and we could reasonably expect this

to continue in the future.

Discounting the VSL of $3.7m from Table 5-1 by the discount rate of 3.3% over an average

40 years expected life span (the average from the meta-analysis of wage-risk studies)

provides an estimate of the VSLY of $162,561.

One of the main costs of chronic pain is the loss of wellbeing and quality of life that it entails.

This can be estimated by initially allocating a disability weight to chronic pain.

The disability weights used in this study are based originally on those calculated by the

AIHW (Mathers et al, 1999), adjusted for comorbidities in people with chronic pain.

musculoskeletal conditions was used and then adjusted for comorbidities to

conservatively estimate an overall disability weight for people with chronic pain

of 0.037.

Based on the disability weight outlined above and the total number of people experiencing

chronic pain, the YLD for chronic pain has been calculated by gender (Table 5-2).

Adopting the conservative approach to deaths from chronic pain discussed in Section 4.1.3,

no YLL are attributed to the cost burden of chronic pain in this analysis.

The overall loss of wellbeing due to chronic pain is shown in Figure 5-1, which illustrates YLD

due to chronic pain totalling 116,742 DALYs. The greatest impact of chronic pain is in the

40-44 age group, reflecting the higher YLD due to the large number of Australians with

chronic pain in this cohort. Indicative of the greater prevalence and hence greater YLD, it can

also be seen that the greatest loss of wellbeing due to chronic pain in Australia is among

women.

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

Female YLD

Male YLD

Multiplying the number of DALYs by the VSLY ($162,561) provides an estimate of the gross

dollar value of the loss of wellbeing due to chronic pain.

The estimated gross cost of lost wellbeing from chronic pain is $18.9 billion

in 2007.

Bearing in mind that the wage-risk studies underlying the calculation of the VSL take into

account all known personal impacts – suffering and premature death, lost wages/income,

out-of-pocket personal health costs and so on – the estimate of $18.9 billion should be

treated as a ‘gross’ figure. However, costs specific to chronic pain that are unlikely to have

entered into the thinking of people in the source wage/risk studies should not be netted out

(eg. publicly financed health spending, care provided voluntarily). The results after netting out

are presented in Table 5.4.

Less production losses net of tax 6,155

Less health costs borne out-of-pocket 1,315

The net cost of lost wellbeing due to chronic pain is estimated to be $11.5 billion

in 2007.

The economic cost of chronic pain in 2007 is summarised in Table 6-1.

with chronic pain.

burden of disease (BoD) component.

system costs (31%), DWLs (11%), carer costs (6%) and other indirect costs (1%).

When analysing the total costs of chronic pain in 2007, productivity costs are the largest

component, comprising around $11.7 billion (34%) and reflecting the relatively high impact

on work performance and employment outcomes caused by chronic pain. BoD accounts for

the next largest share at around $11.5 billion (also around 34%). Health system costs

represent a further $7.0 billion (20%) - capturing the considerable inpatient, outpatient and

OOH medical costs, as well as smaller costs such as pharmaceuticals, other professional

services and residential aged care. The opportunity cost of informal care is around $1.3

billion (4%), while other indirect costs (such as aids and modifications) are around $0.3 billion

– or 1% of total costs. DWLs from transfer payments (taxation revenue forgone and welfare

payments – notably DSP and NA) comprise the final $2.6 billion (7% of total estimated

costs).

The largest share of chronic pain costs is borne by the individuals with chronic pain

themselves who, principally due to the large BoD costs, bear 55% of total costs; 22% of total

costs are borne by the Federal Government, due primarily to their share of health system

and productivity costs. Employers bear 5%, State Governments 5%, family and friends bear

3%, while the remaining 10% is borne by society.

If just the financial costs are considered, the relative shares by bearer are shown in

Figure 6-3, with Federal Government bearing the largest share (33%), closely followed by

individuals (32%).

Note: numbers may not sum to 100% due to rounding.

This section makes comparisons with other conditions, and describes some cost effective

interventions for preventing and managing chronic pain. Comparisons can be useful where

relative prioritisation is important in strategic planning for future health budgeting and

research, including relative to total health expenditure and gross domestic product.

2005 is the most recent year for which comparable prevalence data on all diseases are

available and Figure 7-1 below depicts the prevalence of chronic pain relative to selected

other conditions. In 2005, chronic pain prevalence was comparable or higher than a number

of National Health Priority Area (NHPA) conditions including mental and behavioural

disorders, asthma and diabetes.

0 2,000 4,000 6,000 8,000 10,000 12,000

Infectious & parasitic

Blood & blood forming organs

Neoplasms*

Genito-urinary system

Diabetes melitus*

Skin & subcutaneous tissue

Nervous system

Asthma*

Mental & behavioural*

Hearing loss

Chronic pain

Cardiovascular*

Musculoskeletal*

Visual disorders

Prevalence (thousands of people).

* National health priorities.

Source: Access Economics based on ABS NHS 2004-05.

Note: Chronic pain, in addition to being a condition in its own right, is also an important component of NHPA conditions, for

example cancer, musculoskeletal diseases and injuries.

The most recent comparable data across diseases for health expenditure in Australia are for

Australia (AIHW 2005) (Figure 7-2).

0 1,000 2,000 3,000 4,000 5,000 6,000

Asthma

Diabetes mellitus

Stroke

Depression

Ischaemic heart disease

Cancer

Mental disorders

Other Cardiovascular conditions

Injuries

Chronic pain

Musculoskeletal conditions

Cardiovascular diseases

Source: Access Economics based on AIHW (2005).

Note: Chronic pain, in addition to being a condition in its own right, is also an important component of NHPA conditions, for

example cancer, musculoskeletal diseases and injuries.

Allocated health expenditure on chronic pain was estimated as around $4.4 billion in 2000-01

– the most recent year for which there are comparable health expenditure data across

diseases. This was third only to cardiovascular diseases and musculoskeletal conditions

among the NHPAs, while noting the overlap between costs of chronic pain and its underlying

causes.

estimated spending on chronic pain ranks highly relative to many of the NHPAs –

outstripping allocated health spending on conditions such as injuries and mental

disorders.

The most recent data available comparing the BoD from different conditions in Australia is

the recent AIHW publication relating to the year 2003 (Begg et al, 2007).

comparable to that of diabetes and of musculoskeletal conditions, and ranked higher

than asthma, which is a NHPA (Figure 7-3).

0 100 200 300 400 500 600

Asthma

Musculoskeletal conditions

Chronic pain

Diabetes Mellitus

Injuries

Mental disorders

Cardiovascular

Malignant Neoplasms

Source: Access Economics (2007) and Begg et al (2007).

Note: Chronic pain, in addition to being a condition in its own right, is also an important component of NHPA conditions, for

example cancer, musculoskeletal diseases and injuries.

Comparing the total costs of chronic pain with other conditions is hampered by the fact that

there are few disease cost burden analyses published in Australia. Presented in Table 7-1 is

a comparison of the total costs of a number of conditions, as estimated by Access

Economics in recent studies. While direct comparison between studies is not possible due to

the different base years used, Table 7-1 does provide an insight into the significant size of

the costs associated with chronic pain in Australia.

2007 Arthritis 12.2 11.7 23.9

2007 GORD & PUD^ 9.7 7.2 16.9

2005 Hearing loss 11.7 11.3 23.0

2005 Cancer 11.2 83.4 94.6

2004 Cardiovascular

disease 14.2 93.9 109.1

2004 Vision loss 5.0 4.8 9.9

2004 Restless legs

syndrome 1.4 9.7 11.1

2004 Sleep Disorders* 6.2 4.1 10.3

2003 Bipolar disorder 1.6 n/a n/a

2002 Dementia 6.6 n/a n/a

2002 Schizophrenia 1.8 n/a n/a

2001 Osteoporosis 7.5 n/a n/a

Source: Past Access Economics reports.

^Gastro-oesophageal reflux disease and peptic ulcer disease.

* Obstructive sleep apnoea, insomnia, periodic limb movement disorder and narcolepsy.

The results from this report and previous research indicate that chronic pain has a significant

impact on health spending as well as the economy as a whole. This impact is likely to

increase as the population ages over the coming decades.

As medical technology advances, patient care and treatment is changing in many ways.

However, unlike technological change in other industries, which is often cost-reducing, many

technological advances in health result in increased costs (eg. new large molecule

pharmaceuticals, greater use of newer diagnostic procedures). Demographic ageing is

another cost driver, with health costs per person much higher in older age. Finally, health is

an income-elastic good, which means that as the standard of living increases over time,

Australians spend a higher proportion of household income on health, with higher

expectations of the quality of care.

Intergenerational Report 2007, which outlined that Commonwealth spending on health

is projected to grow significantly over the next 40 years increasing as a proportion of

GDP from 3.8% in 2006-07 to 7.3% in 2046-47.

Given the projected financial pressures, spending on health, like any form of expenditure, is

likely to be subject to a binding budget constraint and this limits both the quality and the

quantity of health services that can be provided, in particular through publicly financed

mechanisms. In this context, evaluating and comparing health interventions in terms of their

ability to achieve their ultimate goal – effective, efficient improvements in quality of life – is

vital to ensuring efficient allocation of these scarce resources.

terms of their ability to provide health and other benefits, relative to the cost of the

intervention. The most common type of cost effectiveness analysis in health is cost utility

analysis, which compares the net financial cost of the intervention with the wellbeing benefit,

measured in dollars spent per QALY gained (ie, $/QALY). Expensive treatments can be cost

effective if they confer significant value to a person in terms of longevity and quality of life.

Conversely, expensive treatments are not cost effective if they offer only small wellbeing

gains relative to their costs.

such an extent that entry to nursing home care is delayed or averted.

than the comparator (the alternative being analysed).

There is a variety of opinion on where bounds for cost effective interventions lie and,

furthermore, no common thinking has emerged on thresholds for incremental cost

effectiveness ratios that might be used in public reimbursement decision-making processes.

The economic evaluation literature on chronic pain treatments is in urgent need of further

development. Economic evaluations of community-wide and primary care-based treatments

are needed, given the size of the problem of chronic pain in the Australian community.

There are few published analyses of the economic impact of chronic pain treatments and

most of these are related to MPCs or their components. Recent expert review of treatments

for chronic non-specific low back pain (eg. Assendelft et al, 2004) was unable to locate cost

effectiveness studies for many of the treatment modalities used in this significant chronic

pain population group.

However, a more useful perspective in this context may be to consider the related concept of

cost-benefits of pain treatments. It should also be recognised that, as much of persistent pain

is currently intractable to curative interventions, effectiveness should be gauged not from

complete pain relief, but rather minimising impact of persisting pain on a person’s lifestyle

(quality of life), restoration of functional activities of daily life, and reduced use of health

services.

There is evidence that for the types of patients concerned (i.e. the more disabled,

medication-dependent and higher consumers of health care services), MPCs can offer costbenefit

advantages over other forms of care.

The Audit Commission report (2003) on Anaesthesia Services in the UK included a case

study of one MPC. The main findings indicated that the number of consultations with other

specialists, particularly surgeons, did drop significantly in the 6 months following attendance

at the MPC, relative to the 6-month period before the MPC. Overall, the findings indicated

that the MPC covered its costs by reducing consumption elsewhere within the local health

system and there were cost savings achieved through fewer GP consultations. Patients also

sought fewer private treatments following attendance at the MPC.

In a review of the Oxford Regional Pain Relief Unit (UK), McQuay et al (1997) considered the

disease burden represented by the conditions typically seen in MPCs, estimating the

probable levels of change achieved and assessing whether MPCs added to costs (to the

health system) or reduced them. Extrapolating from some Canadian data, McQuay et al

concluded that in 1 year ‘the use of MPCs results in direct health service savings equal to

twice their cost’ (pp. 113).

More recently, Gatchel and Okifuji (2006) examined a number of published studies that had

evaluated the clinical effectiveness of common pain treatments and calculated their cost

effectiveness in relation to the costs incurred in returning a patient to work. While

acknowledging the inherent methodological difficulties in his investigation, Turk (2002a)

concluded that multidisciplinary pain rehabilitation programs achieved significantly better

outcomes on a range of dimensions than other pain treatment modalities. The outcomes for

which these programs were superior to other modalities studied included medication use,

health care utilisation, functional activities, return to work, closure of disability claims and

substantially fewer iatrogenic consequences and adverse events. He also found that surgery,

spinal cord stimulators and implanted drug delivery systems (IDDS) achieved substantial

benefits for selected patients, but they were also the most expensive options. Overall,

Turk (2002a) concluded that multidisciplinary pain rehabilitation programs are significantly

more cost effective than spinal cord stimulators, IDDS, conservative care and surgery, even

for selected cases. However, Molloy et al (2006) did show that improved functional outcomes

could be achieved when a multidisciplinary program was combined with either an IDDS or

SCS for the most disabled cases.

Appendix 2 provides examples of recent studies of the cost effectiveness of different

treatment modalities for chronic pain, where such studies exist. by comparing this with the

preceding sections, it becomes apparent that there are many gaps in the cost effectiveness

literature for chronic pain treatments. The complexities of Australian federal-state health

funding mechanisms and differences in health care delivery systems between countries

suggest that Australian-based economic evaluation studies are required.

9 The material for the following section was largely derived from Nicholas (2004).

This report shows that chronic pain is a surprisingly common condition in Australia and has a

substantial economic impact on society due to its prevalence and the various widespread

impacts on people who experience it and those caring for them. This, as well as the

relationship between chronic pain and socioeconomic disadvantage, makes it an important

public health concern in Australia. However, there are relatively few Australian data on the

prevalence of chronic pain, its progression, and its impact on individuals and health services

and the broader community.

There is a growing emphasis on developing multidisciplinary management strategies for

chronic illnesses such as chronic pain. In response to a demonstrated need, five medical

specialties (Anaesthesia, Medicine, Psychiatry, Surgery, and Rehabilitation Medicine)

co-operated in the formation of a multidisciplinary Faculty of Pain Medicine (FPM) housed in

the Australian and New Zealand College of Anaesthetists (ANZCA). The FPM Board includes

representatives of all five specialties – a unique body internationally. The Board oversees a

single training program and examination in Pain Medicine, approved by the Australian

Medical Council (AMC). In 2005 Pain Medicine was approved as an independent medical

specialty. There is an apparent major shortage of Pain Medicine specialists relative to

demand, and a lack of funding for training positions and of resources (funding and staff) for

MPCs.

Chronic pain is a complex multidimensional phenomenon. The current report has collected

the available data on epidemiology in order to estimate the economic impact. However, there

are a number of areas where data are nonexistent or data quality could be improved.

of 0-14 years). While the experience of experts in the field suggests that chronic pain in

children is at least as prevalent as that experienced by adults, the lack of survey data

makes the impact difficult to estimate.

chronic pain to disabling chronic pain.

particularly for Australia.

especially those with cognitive impairment.

apportion the health and other costs due to chronic pain. An AFs approach was taken

in this report to estimate health system costs. However, a more detailed and direct

analysis of health costs would be beneficial, controlling for other factors. This would

also assist in relation to the BoD calculations, where there is also need for better

estimation of disability weights for chronic pain, including by severity.

chronic pain, at the individual, systems (eg. workplace) or community level.

sickness presenteeism.

could then be used to better inform health system effects and other elements of the

impact and management of chronic pain.

This report outlines that chronic pain has a significant impact on a person’s ability to work

effectively or at all. This imposes real costs on the Australian economy, which is already

running at near full employment and can ill afford to lose productive capacity.

There are a number of factors that have the potential to inhibit the recruitment and retention

of people with chronic pain, and their ability to work at optimal productivity levels, including

the following.

to emphasise retention and protection of existing jobs (rather, finding ‘new’ jobs for the

unemployed).

of adaptive technology) which, in turn, limits workplace access for individuals with

chronic pain and can lead to the loss of workers as people are forced out of work

prematurely.

working with chronic pain, and stigma (especially if the cause of the pain is not known).

known, forcing the problem underground and potentially increasing the size of the

problem in the future both for the employee and the employer.

chronic conditions such as pain can be problematic. Many prospective employers

require details of pre-existing disabilities with consequent reluctance to take on those

whose capacity to perform a full range of employment duties is doubted.

hiring workers with a chronic illness. Accordingly, many people with chronic pain can

have fractured working lives or are unable to maximise their earning capabilities by not

being able to advance their employment status or by being limited in overtime capacity.

An additional obstacle for people with chronic pain can be the additional time, effort

and cost commuting to work, negotiating traffic or public transport.

A key challenge is in introducing seamless employment support programs that involve

innovative strategies such as workplace environment adaptation, job restructuring or

tailoring, part-time and flexible work-from-home options, and transport assistance, as

appropriate. Workers compensation ‘return to work’ or rehabilitation models may be useful –

these can determine work capacity on an individual basis. Incentive regimes are also

possible that recognise efforts made by both parties in adapting and maintaining employment

arrangements.

The section above suggests that early assessment and intervention should be encouraged

where reports of pain are limiting the ability of Australians to return to work. This could help

avoid unnecessary suffering, increasing disability, and associated legal and other costs

(Molloy et al, 1999).

This process could be facilitated through awareness and education of both people with

chronic pain and society as a whole (eg. medical practitioners, employers, and carers). In the

workplace context, these strategies are needed to counter workplace misperceptions and

discrimination against people with chronic pain, and that induce cultural change among

employers and employees to identify and implement positive long term solutions. These

should cultivate ‘success factors’, namely:

and sensitivity to the employee’s needs;

Equal Opportunity legislation;

being able to work outside normal hours;

work; and

accommodation, information provision and disclosure issues.

Challenges in ensuring the quality of care for people with chronic pain and other chronic

illnesses can include:

health, community health and general practice, particularly in certain areas;

of awareness in relation to chronic pain; and

chronic and sometimes progressive illness, compared to acute illness with a ‘cure’.

Given that the majority of care for people with chronic pain tends to occur in the informal

context, appropriate support is also required for informal carers.

Adequate ongoing funding injections are required to increase services to carers, in particular

for education, peer support and respite. Access Economics (2003) showed that some

programs that provide these services to carers can have seven-fold returns in terms of

improving the quality of life of carers and the people they care for and delaying costly

institutionalisations.

Given the link between chronic pain and lower SES, attention needs to be paid to

disadvantaged groups.

and workforce adequacy (notably medical) is poorest. Smarter use of new information

technologies can assist in delivering health and support services to people in rural and

remote areas, including web-based information resources and messaging, moderated

chats and forums, videoconferencing and clinical communications.

diverse backgrounds. People from non-English speaking backgrounds can face added

challenges in relation to identifying chronic pain, language barriers (eg. translation of

information and support materials), employment obstacles, culturally appropriate

services, and individual customs, traditions and values. These Australians have equal

right to access affordable, quality chronic pain assessment and care services, which

can only be available for them if specialist resources are developed to promote access.

Chronic pain is a diverse condition often requiring treatment from a range of health care

professionals, including medical specialists required to be knowledgeable about the

management of challenging pain problems in paediatric, adult and geriatric patients across a

wide medical specialty field.

Furthermore, there is an overlap between pain medicine and other medical fields, including

rehabilitation, palliative care and occupational health.

The recognition of chronic pain as a complex multidimensional phenomenon has focussed

attention on limiting a poorly coordinated uni-dimensional approach to assessment and

treatment, which is less effective and more costly than multidimensional treatment.

management approach covering a range of medical specialties can reduce financial

costs. It can also return individuals to work who would otherwise be unemployed or not

participating in the workforce.

The discussion in this section outlines a number of challenges for the management of chronic pain and indicates that the condition can be best managed in a collaborative and multidisciplinary fashion. Improved outcomes will require appropriately trained health professionals to assess and treat the broad range of problems in patients with chronic pain.

While the majority of people with chronic pain should be managed effectively by coordinated services at the community level, a proportion will require the resources of multidisciplinary pain management centres. These centres utilise the services of a range of health professionals to assess the multidimensional aspects of pain and to design appropriate programs of treatment aimed at control of pain, including rehabilitation and improvements in functional outcomes.

This table applies to the management of chronic pain not the treatment of specific conditions, such as cancer or arthritis but, rather, where the

pain has been present daily for more than three months since onset and the focus of treatments is the relief or control of pain as well as limiting

its impact on the person’s functional activities (reducing disability)

Key:

Effects: o = no effect; + = some benefit; ++ = medium benefit; +++ = marked benefit; - = adverse effect; ? = unknown or conflicting

Strong: +++ Consistent findings among multiple high quality RCTs**

Moderate: ++ Consistent findings among multiple low quality RCTs and/or CCTs and/or one high quality RCT

Limited: + One low quality RCT and/or CCT

Conflicting: C Inconsistent findings among multiple trials (RCTs and/or CCTs)

** There is consensus among experts that strong evidence can only be provided by multiple high quality trials that replicate the findings of other

researchers in other settings.

RCT: Randomized Controlled Trials (generally considered the strongest level of evidence for a treatment)

CCT: Case Controlled Trials (when RCTs may not be feasible, can provide next strongest level of evidence)

2007

Cost effectiveness of physiotherapist-led “patient

active” treatments for chronic low back pain (eg

simple exercises without special equipment and

education) vs. usual outpatient physiotherapy

Cost-saving

Critchley

et al, 2007

2006

Cost effectiveness of comprehensive pain

programs vs. conventional medical treatment for

chronic nonmalignant pain

Cost-saving

Gatchel &

Okifuji,

2006

2006

Cost-utility of interdisciplinary chronic spinal pain

treatment vs. traditional medications and

procedures alone – retrospective case study in

the USA

Cost-saving

US$57,627/QALY

to $75,885/QALY

Hatten et

al, 2006

2002

Comprehensive pain rehabilitation programs

(PRPs) (eg multidisciplinary pain treatment) vs.

other treatments for chronic pain (eg spinal cord

stimulation alone) – literature review

Cost-saving

Gatchel

and Okifuji

(2006)

2002

Cost effectiveness of a light multidisciplinary

treatment program vs. an extensive

multidisciplinary program for patients with chronic

low back pain (including outcomes in terms of

returning to work after pain) – randomised control

trial in Norway

Cost-saving for

men only

Haldorsen

et al, 2002

2007

Effectiveness of nonnarcotic protocol for the

treatment of acute exacerbations of chronic

nonmalignant pain vs. narcotic interventions –

prospective observational study in the USA

Cost-saving, in

terms of hospital

utilisation

Svenson &

Meyer,

2007

2007

Cost effectiveness of a vaccine to prevent

pain-causing herpes zoster (“shingles”) vs.

alternative therapy (eg antiviral drugs) in older

adults

Dominated for

most age groups

Rothberg

et al, 2007

2006

Economic evaluation of oral treatments for

neuropathic pain (comparison of amitriptyline,

carbamazepine, gabapentin, and tramadol)

Amitriptyline and

carbamazepine

are more cost

effective than

tramadol and

gabapentin

Cepeda &

Farrar,

2006

2006

Cost effectiveness of various triptans for acute

migraine therapy (comparison of almotriptan,

eletriptan, naratriptan, rizatriptan, sumatriptan,

and zolmitriptan)

Almotriptan 12.5

mg and rizatriptan

10 mg (Maxalt)

most cost

effective

Kelman et

al, 2006

Continued next page

2007

Cost effectiveness and cost-utility of

treating failed back surgery syndrome

using spinal cord stimulation (SCS)

versus reoperation – RCT in the USA

Cost-saving

North et al,

2007

2006

Cost effectiveness of spinal cord

stimulation (SCS) in complex regional

pain syndrome (CRPS) and refractory

neuropathic back and leg pain/failed

back surgery syndrome (FBSS) vs.

alternative therapy (eg physical therapy

alone) – RCT and meta-analysis

Cost-saving in the

long-run

Taylor, 2006

2006

Cost effectiveness of spinal cord

stimulation (SCS) in the management of

patients with complex regional pain

syndrome (CRPS) vs. physical therapy

alone – RCT in the UK

Cost-saving

(US$23,480/QAL

Y)

Taylor et al,

2006

2004

Cost-benefit analysis of neurostimulation

of the spinal cord and peripheral nerves

for chronic pain

Cost-saving in the

long-run

Mekhail et al,

2004

2004

Cost effectiveness of initial lumbar fusion

vs. nonsurgical treatment for chronic low

back pain - randomised, controlled trial

from the Swedish Lumbar Spine Study

Group

Cost-saving

Fritzell et al,

2004

2004

Cost effectiveness of spinal cord

stimulation in the treatment of pain vs.

other therapy (eg physical therapy alone)

– literature review

Cost-saving in the

long-run

Taylor et al,

2004

2002

Cost effectiveness of spinal cord

stimulation (SCS), compared with best

medical treatment/conventional pain

therapy – group of patients with failed

back syndrome in Canada

Cost-saving in the

long-run despite

high initial cost of

implantable

devices.

Kumar et al,

2002

2005

Combined manipulative treatment,

stabilising exercises, and physician

consultation compared with physician

consultation alone for chronic low back

pain – RCT in Finland

Dominated

Niemisto et al,

2005

2005

Cost effectiveness of chiropractic vs.

primary medical care for acute and

chronic low back pain (LBP)

Cost-saving in the

short term for

chronic LBP

Haas et al,

2005

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