Waiting for Chronic Pain Treatment: Impact on Patients and Considerations for Tertiary Services

Abstract

Chronic pain (CP) is a costly, prevalent (20% of adults) and complex condition that often cannot be explained by a single medical diagnosis. Although it has been shown to impact psychological well-being, research examining this relationship has typically adopted a diagnosisspecific lens, rendering it inapplicable to most people with CP. Understanding the psychological impact of CP from a general perspective is therefore important. The Australian public health system manages CP poorly. Most people cannot access treatment, while those who do face lengthy indefinite waits, the impact of which is unknown. Improving access to CP treatment is a health service imperative, for which resource (re)allocation and service (re)design are important considerations. However, there is no data (national, international) regarding staffing (amounts, types) that are employed within multidisciplinary pain clinics, or consensus about models of care that improve access and patient outcomes. Clarification of the impact of lengthy waitlists and these service-related factors (staffing, care model) is needed. These issues were explored via four studies. Study 1 meta-analysed data (Nstudies=110) comparing the psychological functioning of individuals with CP to that of healthy peers. A general, not condition-specific, perspective was used in order to reflect the experience of most people with CP. Results indicated that CP was associated with significant problems across a range of psychological domains; the largest being anxiety, especially pain anxiety/concern, and somatisation. Study 2 then explored the psychological functioning and health care utilisation of individuals indefinitely waitlisted for a first appointment at a tertiary CP service by prospectively following 339 individuals for three years after referral. Findings highlighted the importance of early intervention (<6 months), especially for women, with deterioration in pain-related interference, distress and pain acceptance evident across longer-term waits; albeit with different sex-patterns. Next, Study 3 analysed staffing configurations within Australian multidisciplinary CP services. Staffing was explored as an overall total and as a function of the amount of clinical activity undertaken by the service, thus enabling calculation of individualised resourcing requirements. Results indicated a national consensus in the overall type and amount of staffing employed; the exceptions being psychiatry and occupational therapy. However, clinics that undertook training and research activities appeared to employ comparatively greater medical staff per patient load, while those who did not employed comparatively more allied health. Finally, Study 4 evaluated whether a group-based pain education session — a resource neutral model designed to expedite treatment access — delivered immediately after referral to a tertiary CP service (pre-clinic) improved outcomes for waitlisted individuals (N=346). Despite reasonable acceptance, session attendance was not associated with functional improvements, although referral to (not treatment by) the service was. Together, these findings suggest that CP profoundly impacts psychological well-being, especially anxiety, and this is exacerbated by lengthy indefinite waits for treatment. Accordingly, treatment should include an anxiety focus and be delivered within six months of referral. However, as staffing resources did not independently determine waitlist length, timely service delivery requires more than extra funds. Pre-clinic education can facilitate this through service factors (e.g., nonengagement), but may not improve patient outcomes.