Living with chronic pain. Understanding and causes vary widely. Pain management. The stigma of pain 20% have considered suicide

ISSUE #46 – CHRONIC PAIN In this issue: Australians Living with chronic pain Understanding – and causes – vary widely Fewer than one in five are sa...
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ISSUE #46 – CHRONIC PAIN

In this issue: Australians

Living with chronic pain Understanding

– and causes – vary widely Fewer than one in five are satisfied with their

Pain management The stigma of pain 20% have considered suicide

A holistic approach

aids pain management

Pain costs the community

$34.3 billion annually Help is available

Other key findings Useful links and resources

Welcome to the Pfizer Health Report In this issue we focus on the issue of chronic pain – a condition that affects 29% of Australians, which means that nearly three in 10 people are experiencing chronic pain at any given time.1 Defined as ‘pain that extends beyond expected healing time’2, chronic pain is a condition that 92% of Australians are familiar with.3 Even if we don’t experience chronic pain ourselves, 61% of Australians know someone who lives with the condition.4 Twenty per cent (20%) of Australians live with a person who has chronic pain.5 Despite the remarkably widespread nature of chronic pain, many people with the condition feel it is poorly understood. Among Australians who experience chronic pain, 56% say other people have only a slight understanding of chronic pain and 36% believe there is no understanding at all.6 Along with the discomfort of pain, this lack of understanding can see people with chronic pain being stigmatised, and 20% of those who live with chronic pain say that at some stage they have considered taking their own life as a result of their pain.7 In this edition of the Pfizer Health Report, we look at the causes of chronic pain, as well as possible treatment and management strategies, and the cost to the community.

Contents Foreword.............................................................................................................................................................................................................................3 Australians living with chronic pain..........................................................................................................................................4 Understanding – and causes – vary widely.................................................................................................................5 Fewer than one in five are satisfied with their pain management.........................................6 The stigma of pain – 20% have considered suicide, according to this survey...7 A holistic approach aids pain management ............................................................................................................8 Useful links and resources.......................................................................................................................................................................9 Pain costs the community $34.3 billion annually......................................................................................... 12 Help is available................................................................................................................................................................................................. 14 Other key findings........................................................................................................................................................................................... 15

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Abou

the rese

Foreword As a person who has lived with chronic pain, I am familiar with the debilitating effect it can have on day-to-day living. And I am certainly not alone. Almost one in three Australians experience chronic pain8, making it one of our most widespread health issues. The results of this Pfizer survey confirm that chronic pain isn’t just a significant health issue – it is also widely misunderstood. Only 9% of people with chronic pain feel that others have anything more than a slight understanding of chronic pain.9 In many cases, people with chronic pain feel that others doubt the reality of their pain – only 21% say the reality of their pain is “never” doubted.10 In addition to the stigma sometimes created by those ‘doubting Thomases’, people with chronic pain often face challenges when it comes to managing their pain. According to research undertaken last year, forty-one per cent (41%) of people with chronic pain are to some extent dissatisfied with the way their pain is managed.11

out

earch

Living with pain isn’t easy, and we should all be concerned by statistics that show 20% of people with chronic pain have

considered taking their own life as a result of their pain.12 This research puts us at the forefront of being prepared to confront the reality of living with chronic pain. While it isn’t pleasant, it is time we faced up to this reality and started to do something about it. Clearly there is a need for better education and community understanding of chronic pain. I invite you to take a look through this issue of the Pfizer Health Report to learn a little more about chronic pain and its impact on people like you and me. We can all make a difference if we take the time to better understand the facts about living with chronic pain. This research goes some way to highlighting some of these facts. Coralie Wales, President Chronic Pain Australia

The Pfizer Health Report Chronic Pain Survey was carried out by StollzNow Research using a quantitative permission-based online panel of 2,511 Australian adults aged 18 years and over. To ensure that the survey is representative of the Australian adult population quotas were set for gender, age, state and region (metropolitan and rural and regional areas). This sample size gives an approximate confidence level of plus or minus 2% at the 95% confidence interval. CHRONIC PAIN | HEALTH REPORT | 3

Australians living with

chronic pain It is extraordinary to think that almost one in three Australians live with chronic pain on a daily basis.13

Research by Pfizer Australia reveals the alarming extent of chronic pain in modern society. Overall, 29% of Australians say they experience chronic pain.14 Women (31%) are more likely to experience chronic pain than men (26%).15

“Emerging research confirms that brain patterns during the experience of pain are different between men and women, and there may be a myriad of reasons for these differences including hormonal and other biological factors as well as genetic and evolutionary causes.”17

Chronic pain is not restricted to the elderly. It is reported across all age groups, ranging from 19% of people aged 18-29, to 29% of those aged 66 and over.16

Personal income can play a role. Chronic pain is more prevalent among low income earners, peaking at 36% for those who earn between $20,000 and $35,000 annually, and reaching its lowest level of 24% among those whose annual income exceeds $100,000.18

Explaining the higher rate of chronic pain among women, Coralie Wales, President of Chronic Pain Australia says,

What is meant by

‘chronic’ pain? Coralie Wales, President of Chronic Pain Australia says, “Chronic pain is defined as pain that extends beyond the expected healing time of an injury, or can accompany chronic illnesses such as arthritis or lupus.” Some people define chronic pain as simply lasting longer than 3-6 months. Although 20% of Australians regard chronic pain as ‘intense pain’19 Wales says, “Chronic pain can be intense, however the word ‘chronic’ relates to duration rather than the quality of the experience. Some people experience chronic pain of mild intensity.” She adds, “It is important to distinguish chronic pain from acute pain. Normal, short term pain associated with an 4 | HEALTH REPORT | CHRONIC PAIN

injury is ‘acute pain’ and as the injury heals, the pain usually goes away.” Adjunct Associate Professor Ron Tomlins, Discipline of General Practice, University of Sydney, adds that the word ‘chronic’ has a specific, technical meaning for health professionals, but means absolutely nothing to most of the general public. “In a lot of countries, they use the phrase ‘long term’ pain rather than ‘chronic pain’ to make the distinction with intense, short term pain,” says Tomlins. “It’s important to make this distinction because ways to manage long term pain can be different to managing intense, short term pain.”

Understanding – and causes –

vary widely

The vast majority of Australians (92%) have heard of chronic pain20 but understanding of the condition varies widely – and so do the causes. Among those Australians who experience chronic pain, 56% say other people have only a ’slight understanding’ of chronic pain, while 36% of chronic pain sufferers say there is ‘no understanding’ of their pain by other people.21

Uncovering the causes Among those who experience chronic pain, 47% say it is the result of a diagnosed condition such as arthritis, an inflammatory condition, multiple sclerosis or cancer22. Forty per cent (40%) say chronic pain has followed from a life event such as an operation or accident-related illness.23 However, for 13% of people with chronic pain there is no identified medical reason for their pain24 and Coralie Wales, President of Chronic Pain Australia says, “This can be the most frustrating type of pain, when no obvious cause appears on any scans or x-rays.”25

Dealing with the doubters Wales notes, “Pain is real even when there is no medical explanation. The

biggest issue for some people living with chronic pain is that others often don’t believe their pain is real. When the person suffers compromised social outcomes as a result of their pain being seen as invalid, the person is experiencing ‘stigma’.”26 There is no doubt that stigma occurs. Twenty-one per cent (21%) of people with chronic pain say they often feel people doubt the reality of their pain, and 58% say people ‘sometimes’ doubt the reality of their pain.27 The National Pain Strategy, developed in early 2010, is the first comprehensive pain initiative in Australia – and worldwide. It aims to improve the quality of life for people with pain and their families, and to minimise the burden of pain on individuals and the community.28 Non-profit organisations such as Chronic Pain Australia support the strategy and provide support and education for people in pain and those people who care for or are concerned for them. Wales says, “Chronic Pain Australia is working towards the destigmatisation of chronic pain and if people feel disconnected as a result of chronic pain they can call Chronic Pain Australia’s National Chronic Pain Information Line for assistance and support.”29

Chronic Pain Australia: National Chronic Pain Support and Information Line

1800 218 921

CHRONIC PAIN | HEALTH REPORT | 5

16% Satisfied

Fewer than

14% Dissatisfied34

one in five 27% Somewhat dissatisfied32

are satisfied with their pain management

43% Somewhat satisfied33

Among those Australians who experience chronic pain, only 16% are satisfied with how their pain is being managed.30 For those who experience chronic pain, managing their condition can be difficult and this may be compounded by a lack of information.

People who experience chronic pain rate their satisfaction with their pain management as follows: 16% Satisfied31 27% Somewhat dissatisfied32

“One in five Australians, including children and adolescents, will suffer chronic pain in their lifetime and up to 80% of people living with chronic pain are missing out on treatment that could improve their health and quality of life.”36 National Pain Strategy

43% Somewhat satisfied33 14% Dissatisfied34

People aged 50-59 are more likely to be satisfied with their pain management, while dissatisfaction is higher among people aged 30-49.35

Insufficient information compounds the problem Only 10% of people with chronic pain say they have an ‘excellent’ level of information about their pain. Thirtyfive per cent (35%) have ‘some’ information but 17% report having ‘not enough information at all’.37 Coralie Wales, President of Chronic Pain Australia says, “It’s not acceptable to just have ‘some’ information about a condition such as chronic pain. Clearly there isn’t enough information getting through at the level of primary care, general practitioner or hospital. This is another indicator that we need to do more to educate people about chronic pain.”38 “For people looking for information about their chronic pain, most people firstly seek the advice of their doctor or other trusted health professional, or they may contact organisations such as Chronic Pain Australia,” adds Wales.39 6 | HEALTH REPORT | CHRONIC PAIN

Adjunct Associate Professor Ron Tomlins, Discipline of General Practice, University of Sydney, adds that in his clinical experience there can often be a disconnect between the expectations of people with chronic pain and the expectations of their health professionals about what relief can be reasonably achieved. “If someone has an expectation that there is a magic pill that can make their pain go away immediately, they will be dissatisfied,” says Tomlins. “If someone with a chronic back problem wants a strong analgesic so they can mow the lawn then they will be dissatisfied with their pain management even though their own behaviour has compounded the problem. Likewise, if an older person believes they should be able to do what they could when they were 20, they’re never going to be satisfied.”

The stigma of pain

20%

have considered suicide, according to this survey

For 13% of people who suffer chronic pain, there is no medical explanation for their pain.40 An alarming 20% have considered taking their own lives as a result of their pain.41 Five percent (5%) of Australians with chronic pain have attempted to commit suicide because of their pain42 and a further 20% have thought about suicide.43 As noted earlier, only 48% of people with chronic pain rate the information about their condition as ‘good’ or ’excellent’, leaving the majority with insufficient information about their condition.44 Compounding this, 79% of Australians who experience chronic pain feel other people doubt the reality of their pain.45 Coralie Wales, President of Chronic Pain Australia, believes these factors contribute to suicidal thoughts, saying, “People consider ending their life as a result of a combination of the pain, the isolation, the stigma and medicines not working.”46

The challenge to survive Dr Susie Lord, Pain Medicine Specialist, John Hunter Hospital, Newcastle NSW says, “It does not surprise me that 20% of people with chronic pain had thought about suicide. Patients with consistent pain often mention thoughts that ‘life is hopeless’ because the pain has taken away an aspect of their lives that gave them meaning. If they are a mother or father and can’t be the kind of parent they’d like to be, they feel a real loss.” Lord adds, “Suicide can be a thought that crosses a person’s mind and is quickly dismissed. But there are people who actually put together a plan of how they will commit suicide. It’s only intervention through talking to others that stops them from going forward with their plans. Part of our job as health professionals is to listen to people, and when we hear comments along the lines that ‘things are hopeless’ and ‘life’s not worthwhile’, it’s clear that person wants help and we must respond appropriately.” “A burden shared is a burden lightened,” notes Lord. “If you’re thinking about or planning suicide, it’s important that you seek help. Another person may not be able to take the pain away, but having someone listening and caring will make carrying out a plan for suicide much less likely.” She concludes, “If you’re not comfortable talking to friends or family, there are lots of help lines provided by the likes of Chronic Pain Australia, Lifeline and beyondblue. General practitioners and emergency departments can provide advice on where to go for help.”

“My pain is bearable, but sometimes it is really bad. Have had many tests, but they cannot find what the problem is.”47 CHRONIC PAIN | HEALTH REPORT | 7

A holistic approach: aids pain management Australians who live with chronic pain seek advice about their condition from a variety of sources48 but a holistic approach may achieve the best results. The vast majority (91%) of people who have chronic pain consult their doctor about their condition.49 Forty-five per cent (45%) also visit a physiotherapist; 29% speak with a pharmacist and 22% consult a pain specialist.50 A proportion (23%), also seek out help from ‘other’ (undefined) sources.51

Only 22% of people with chronic pain have attended a pain clinic52 Coralie Wales, President of Chronic Pain Australia says, “Some medicines are helpful in managing chronic pain but these are often not the whole story. Although many people are concerned about medicines, this apprehension can work against them if they haven’t trialled various options to see what might help. Many people manage their pain by using medicines ranging from paracetamol through to opiates, but using medicines wisely according to best practice is vital.” Some members of Chronic Pain Australia have used quite high levels of medicines under the care of a pain specialist, according to Wales, and this has enabled them to start practising other types of pain management. She adds,

“Many are able to stop taking these medicines as a result of this strategy. The broader strategy often includes regular exercise that may include walking, Pilates and stretching among many other forms of movement. Finding a balanced way of moving and thinking where you are not overdoing activities – then paying for it later – is one of the keys.”53 Wales adds: “Thinking strategies can also help to calm the nervous system. A person in a high pressure job, for instance, may be on ‘high alert’ all the time. In this situation, meditation can be helpful – even just learning to breathe more slowly.”54

Self management is possible Wales believes, “Chronic pain can be successfully self-managed but to do this, it is essential to achieve a work/life balance. Some play, some leisure and lots of love and laughter are helpful in the self-management of pain.”55 “Different forms of intervention are available including spinal injections and/or implants but a lot of people take a step back to see what they can do themselves before heading down this route,” explains Wales.56

Australia is, in many ways, a world leader in pain management Pain Medicine and Palliative Medicine are established in Australia as independent medical specialties, and our research and education programs are internationally recognised. The need is to translate what we know about what works into the effective delivery of pain management across the health care system.57 National Pain Strategy. 8 | HEALTH REPORT | CHRONIC PAIN

Useful links and resources www.|

Chronic Pain Australia

NPS

www.chronicpainaustralia.org

www.nps.org.au

Health Direct

Posture and Flexibility

What do my blood tests mean?

RSD Community Forum

www.healthdirect.org.au

www.pandf.com.au

www.labtestsonline.org.au

www.ozrsd.org/web/main.htm

Holistic information

Active and Healthy NSW

www.holistic-doc-pain-support.com

www.activeandhealthy.nsw.gov.au

My Doctor for a healthy lifestyle www.mydr.com.au

CHRONIC PAIN | HEALTH REPORT | 9

Living with and beating chronic pain Case study: Margaret Knight (Cherrybrook, NSW)

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Margaret Knight (65) has been living with chronic pain for more than 20 years. During this time she has learnt many skills that have allowed her to successfully self-manage her pain. Yet in the mid-1990s, the ongoing and at times overwhelming nature of her pain saw the mother of three consider suicide. Knight had always enjoyed an active career. In June 1990, she herniated three discs in her spine while unloading groceries. These injuries precipitated three major surgeries to stabilise her spine. While Knight was mostly desk-bound, her employment involved some heavy lifting. “In those days occupational health and safety wasn’t in vogue and we’d struggle with heavy parcels to ready them for the daily courier collection,” she recalls. It was the years of lifting which, according to Knight, probably weakened her back. On the day of her injury, Knight says it was raining. “Rushing to get the groceries inside, I lifted and twisted. The next morning when I woke up, I couldn’t move.” The determined Knight attempted an ultimately futile return to full-time work five weeks after sustaining the injuries. Riddled with back pain, she soon transitioned to semi-permanent work, but was eventually forced out of the workforce as a result of chronic pain. Knight describes chronic pain as ‘totally exhausting’ and something that eroded her self-esteem as she constantly felt the need to convince people she had a legitimate condition. Knight also found it difficult to reliably meet social commitments with family and friends. “It was challenging to go to the movies, picnics and dinner parties,” says Knight. “So gradually your world narrows down to some long term understanding friends.” It wasn’t just the social isolation that prompted thoughts of suicide in Knight. “The trauma of surgery and other

medical interventions caused a kind of inflammation of the lining of my spinal cord. It made my body feel like it was glowing with pain,” she says. “This went on for years. You can’t sleep. It’s never-ending.” Almost overnight, Knight switched from being a bright and active ‘super mum’ and employee to someone who struggled to pour a cup of tea. “I became depressed and I’d be sitting in the bedroom considering whether people would be able to cope without me, while, in the next room, the rest of the family were watching television.” Despite battling with depression, Knight never attempted suicide as she sensibly decided to approach her general practitioner with her concerns. “He sent me to a psychiatrist and it was wonderful to have someone to talk to who I could be totally honest with,” says Knight. “My psychiatrist taught me techniques such as relaxation, self hypnosis and visualisation that really helped.” Working with her medical team, Knight succeeded in overcoming her chronic pain condition using tools like prescribed medication, pacing, hydrotherapy, relaxation training and community outreach. “I felt I had been tortured and escaped and so I am passionate about helping people understand the impact and challenges of living with chronic pain,” says Knight. “That’s why I volunteer with Chronic Pain Australia providing telephone support and participating in other projects that can help.” “The tools to manage chronic pain are different for each individual,” adds Knight. “But I’d urge people to contact Chronic Pain Australia to find out what is available.” CHRONIC PAIN | HEALTH REPORT | 11

Pain costs the

community

Chronic pain has a significant impact not just on sufferers, but also on the broader community, costing the economy $34.3 billion annually.58

The total cost of $34.3 billion includes:

A 2007 report by Access Economics estimates the total cost of chronic pain at $34.3 billion – or $10,847 per person with chronic pain. It is worth noting that it is expected this estimate will increase with time.59

34%

34%

20%

$11.7 billion

$11.5 billion

$7.0 billion

Lost productivity

Burden of Disease

Health system costs, including hospital medical costs, as well as pharmaceuticals, other professional services and residential aged care

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$34.3 billion annually Productivity impacted by both absenteeism and presenteeism

Total cost to employers is estimated at $5.1 billion annually

Clearly one of the most significant costs of chronic pain is lost productivity.

The cost of chronic pain for Australian employers both in terms of absenteeism and reduced work effectiveness (‘presenteeism’) has been estimated at $1.4 billion per year, based on 9.9 million days spent away from work due to pain.62 Taking into account days of reduced effectiveness at work, the total number of lost workdays increases to 36.5 million days, putting the total cost to employers at $5.1 billion annually.63

Access Economics noted that the productivity of those who experience chronic pain isn’t just impacted by absence from work due to pain (‘absenteeism’). ‘Presenteeism’ – or reduced productivity while at work – also presents a real cost to the economy.61

7.0% 4.0% 1.0% $2.6 billion

$1.3 billion

$0.3 billion

Taxation revenue forgone and welfare payments – notably Disability Support Pension and Newstart Allowance

The opportunity cost of informal care

Indirect costs (such as aids and modifications)60

Workers’ compensation claims An estimated 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.64 Twenty per cent (20%) of people who experience chronic pain receive workers’ compensation payments.65 Men (24%) are more likely to be receiving workers’ compensation payments than women (16%).66

People with chronic pa in were more likely to wo rk while experiencing pain than to take time off wo 67 rk. Despite the impact of pain on work performance, people with chronic pain worke d an average of 83.8 days wi th pain over a six month perio d, with 4.5 days taken off work due to pain.68 Access Econom ics CHRONIC PAIN | HEALTH REPORT | 13

Help is available A range of assistance is available for those who experience chronic pain. The National Pain Strategy has acknowledged shortfalls in the current delivery of care for people with chronic pain and has proposed a new model of care involving a pain management network. This will involve strong linkages among primary, secondary and tertiary care levels and among ‘non-pain’ practitioners and those with a special interest in pain.69 Until this system is fully implemented, Coralie Wales, President of Chronic Pain Australia says, “Family, friends, government, health care providers and statutory providers such as WorkCover can all provide help for people who have chronic pain.”70 However she notes, “Doctors are not paid an ‘item fee’ for dealing with people with chronic pain, and this is a systemic barrier to pain management.”71 She adds, “We are encouraging governments to regard chronic pain as a major problem and pointing out that health systems have to reduce the barriers for first line health providers so they can help people in pain.”72 “Governments can make a difference if they focus on chronic pain as a separate condition, which the National Pain Strategy recommends,” adds Wales.

Chronic Pain Australia Chronic Pain Australia was established in 2006 to assist people who experience chronic pain. The aim of Chronic Pain Australia is to partner with the community to run programs that foster and support the self management of pain and which promote further community understanding of chronic pain. Wales says, “The overwhelming objective of Chronic Pain Australia is to destigmatise chronic pain. To do this we must provide public education and information campaigns along the lines of the quit smoking campaigns, and this is something we are working towards.”73 14 | HEALTH REPORT | CHRONIC PAIN

Case study: Luke Arthurs

Living with, caring and supporting someone with chronic pain In 1999, Detective Senior Constable Suzanne Arthurs (now 37) severely injured her back while tracking down an illegal drug laboratory in inner Sydney. Sifting though a garden bed, Suzanne tripped on a wooden stake, fell awkwardly and injured several discs in her spine. As a result, the mother of two has lived with chronic pain for more than a decade. During this time she has endured seven major operations including a back fusion involving the insertion of six screws. Regrettably two of the screws snapped and can’t be removed from her back, which has added to Suzanne’s discomfort. Suzanne was discharged from the NSW Police Force on medical grounds in 2007, and according to husband, Luke Arthurs (39), she is still ‘doing it tough’. “Suzanne was a young, fit healthy person, who is now on daily pain medication, while the many operations to try to relieve her pain levels haven’t helped,” says Arthurs. Unfortunately, there is no definitive cause of his wife’s pain. “The doctors can’t explain why Suz is in pain other than nerve damage,” adds Arthurs. “Luckily she can get around and has part time work at [Sydney’s] Taronga Zoo, however she can’t stand up for any length of time, otherwise she’ll be flat on her back in bed and won’t be able to move.” Arthurs admits to having undergone a major learning curve in relation to his own responsibilities. “Initially, I ignored my role and was hoping I’d wake up one day and everything would be alright,” he said. As a carer for

Other key findings Fifty-six per cent (56%) of people describe chronic pain as long term pain.74 A further 23% say it is pain that continues beyond expected healing times.75

Living with chronic pain 60% of Australians do not think it is always possible to find a physical cause for pain.76

someone with chronic pain, Arthurs admits his ‘head in the sand’ approach continued for a number of years until the couple faced yet another major pain event in 2008. “Suz had a stimulator inserted in her back which was her seventh operation,” says Arthurs. “It protrudes through the skin like a battery pack. It’s about the size of a deck of cards and sends stimulators up her spine.” The operation proved unsuccessful and Arthurs soon recognised there would be no magical cure for his wife. “I realised I needed to deal with it – that we weren’t going back to our old lives,” says Arthurs who, along with Suzanne, became a member of Chronic Pain Australia in 2008. “Before Suzanne hurt her back we used to take driving holidays, but this stopped as she would spend the first two days in bed recovering from the drive.” Yet the determined couple still get away for breaks – Suzanne takes a plane, while Luke drives the children to their holiday destinations. “Everything we do is planned around reducing Suz’s discomfort,” explains Arthurs, who was appointed a board member of Chronic Pain Australia in 2009. Arthurs admits to missing vital signs that his wife was struggling emotionally. “I’d ask my wife how she was doing,” says Arthurs. “But I wasn’t really interested in the answer because I knew it would be the same – and I felt there was nothing I could do.” As a result Arthurs admits to missing signs Suzanne was depressed. “She became quite distressed and needed medical intervention,” says Arthurs, who fortunately recognised his wife’s depression in time and sought treatment. As a result of his personal experience as a carer, Luke Arthurs urges people supporting those with chronic pain to be aware of the emotional and physical well being of their wife, husband, mother, father, relative, friend or colleague.

“Be aware of the ‘now’ and understand there is no magic fix – and don’t ignore what is going on around you,” Arthurs says.

For those who live with chronic pain, their pain can be described as:

67% 20% 12% Aching, throbbing, sharp

Burning, stabbing, tingling, electric, shocklike, freezing

Other/can’t explain77

Attitudes towards chronic pain People who do not have chronic pain believe that:

68%

7%

Pain is either physical or Chronic pain is more likely psychological/emotional to occur when someone has a mental illness

26%

Chronic pain causes mental problems

6%

Chronic pain is an excuse for people who don’t want to work78

“There is now much evidence that…place chronic pain as the third most costly health problem and yet in most countries it has no priority at all as a health problem” – December 2010, Professor Michael J. Cousins AM, ‘Denial of Pain Relief’ presentation to the International Federation of Health and Human Rights Organisations (www.painmanagement.org.au/ content/human-right-pain-relief) CHRONIC PAIN | HEALTH REPORT | 15

1. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 10. 2. Coralie Wales President of Chronic Pain Australia interview with Anthony O’Brien 23 March 2010. 3. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 7. 4. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 9. 5. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 14. 6. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 23. 7. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 42. 8. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 10. 9. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 23. 10. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 24. 11. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 25. 12. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 42. 13. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 10. 14. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 10. 15. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 10. 16. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 10. 17. Coralie Wales President of Chronic Pain Australia interview with Anthony O’Brien 30 March 2011. 18. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 10. 19. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 8. 20. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 7. 21. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 23. 22. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 11. 23. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 11. 24. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 11. 25. Coralie Wales President of Chronic Pain Australia interview with Anthony O’Brien 23 March 2010. 26. Coralie Wales President of Chronic Pain Australia interview with Anthony O’Brien 23 March 2010. 27. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 24. 28. National Pain Strategy, developed by the National Pain Summit initiative, www.painsummit.org.au. Led by: Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine, Australian Pain Society. Chronic Pain Australia, Pain Management for all Australians, page v. 29. Coralie Wales President of Chronic Pain Australia interview with Anthony O’Brien 23 March 2010. 30. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 25. 31. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 25. 32. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 25. 3. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 25. 34. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 25. 35. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 25. 36. National Pain Strategy, developed by the National Pain Summit initiative, www.painsummit.org.au. Led by: Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine, Australian Pain Society. Chronic Pain Australia, Pain Management for all Australians, page 1. 37. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 27. 38. Coralie Wales President of Chronic Pain Australia interview with Anthony O’Brien 30 March 2011. 39. Coralie Wales President of Chronic Pain Australia interview with Anthony O’Brien 30 March 2011. 40. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 11. 41. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 42. 42. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 43. 43. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 42. 44. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 27 (10% “excellent; 38% “good”). 45. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 24 (58% “sometimes”; 21% “often”). 46. Coralie Wales President of Chronic Pain Australia interview with Anthony O’Brien 23 March 2010. 47. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 68. 48. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 26. 49. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 26. 50. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 26. 51. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 26. 52. Stollznow Research for Pfizer Australia: Chronic Pain. April 2010. Page 31. 53. Coralie Wales President of Chronic Pain Australia interview with Anthony O’Brien 23 March 2010. 54. 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16 | HEALTH REPORT | CHRONIC PAIN