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InPsych 2016 | Vol 38

June | Issue 3

Cover feature : Psychology innovation in the public sector

Tapping into a painful problem

With one in five Australians suffering from persistent pain (Blyth et al., 2001) and an estimated cost to the economy of $34 billion per annum (Access Economics, 2007), public sector healthcare resources are stretched thin with up to 80% of patients missing out on treatment that could improve their health related quality of life (Pain Australia, 2010). Whilst research indicates that many different healthcare professionals play a part in effective pain management care, traditional models of care within the public sector have focused on outpatient services led by pain specialists. From its inception in 2010, the Interdisciplinary Persistent Pain Centre (IPPC) on the Gold Coast was a specialist led clinic. In 2014, it was recognised that a longer than acceptable waiting list had arisen, and steps were taken to develop strategies to reduce this list. The wait time was a concern as patients experience a significant deterioration in health related quality of life and psychological wellbeing while waiting for treatment (Lynch et al., 2008).

Refocusing our attention – opening the floodgates

Expert consensus and a growing body of research says that best-practice pain management often requires coordinated interdisciplinary assessment and management involving, at a minimum, physical, psychological, and environmental risk factors for each patient. With the support of the Gold Coast Health Service and utilising aspects of proven programs, the existing service was reviewed and a new, concurrent model of care was introduced. The Treatment Access Pathway (abbreviated to TAP) utilises existing allied health staffing, with the support of the general practitioner (GP) who remains the patient’s primary health care provider. In line with the consensus view (ACI, 2013) and supported by research (Hayes & Hodson, 2011), TAP focuses on a person-centred approach with patients involved in planning their pain management and participating in a time limited service, with access to pre and post measures to gain greater understanding of their progress.

Patients self-navigate their journey at the IPPC, commencing with an introduction to pain education and self-management, continuing with a group assessment day and then engaging in an individually tailored pain management program incorporating both group and individual streams in any combination. Patients are discharged from TAP after completion of their selected journey at which time they can opt to remain on a waitlist to see a pain specialist or continue on with their own self-management. Approximately half the patients seen choose to be discharged without pain specialist input, ensuring effective use of this scarce resource.

Psychological flexibility – calming the raging pain torrent

Research has found both psychological and physical therapy interventions can assist in managing persistent pain (Costa et al., 2015; Morley & Williams, 2015; van Tulder, 2008; Williams, Eccleston, & Morley, 2012). Acceptance and commitment therapy (ACT) has consistently demonstrated its effectiveness with chronic pain (L. M. McCracken & Morley, 2014; Vowles, McCracken, & O'Brien, 2011). Working as an interdisciplinary team, IPPC clinicians deliver the TAP utilising components of ACT with a key focus on psychological flexibility. Both group and individual interventions aim to improve the day to day lives of patients, despite the pain and to refocus attention on values and committed action. Patients are introduced to the concept of acceptance of pain with reorientation to the present moment utilising mindfulness skills.

Reviewing outcomes

TAP is due to celebrate its 2nd anniversary and the outcomes have been remarkable. The waitlist at IPPC has been significantly reduced with waiting time reducing from four years to six months. Preliminary research into patients completing the pathway indicates significant reductions in pain intensity, pain interference, depression and catastrophising. There were also significant increases in pain self-efficacy, quality of life and pain acceptance. Preliminary TAP results are promising and suggest it could indeed increase access, improve health outcomes and reduce costs. Further research is due to commence in mid-2016.

Going with the flow – psychology’s role in changing direction

Psychologists at IPPC work to full scope (first-contact, referring to other professionals, criteria-led discharge) and extended-scope (transdisciplinary skill sharing assessment and discharge) within the Treatment Access Pathway providing a range of opportunities and diversity of roles. Comorbid mental health issues are common for chronic pain patients with depression (Ohayon & Schatzberg, 2010) and anxiety (Asmundson & Katz, 2009) highly prevalent. Core psychological competencies ensure the psychology team at IPPC are skilled in providing individual counselling sessions but also play a key role within group sessions in diffusing emotional distress while also supporting other disciplines in coping with distraught patients. Working within a team, psychologists at IPPC value the contribution of their colleagues, with their discipline specific focus applied to the common, shared understanding of best practice pain management. Together, the team achieve wonderful patient outcomes.

The author can be contacted at Margaret.Vandermost@health.qld.gov.au

References

  • Access Economics. (2007). The high price of pain: the economic impact of persistent pain in Australia. Retrieved from www.bupa.com.au/staticfiles/BupaP3/Health%20and%20Wellness/MediaFiles/PDFs/MBF_Foundation_the_price_of_pain.pdf
  • Asmundson, G. J., & Katz, J. (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art. Depress Anxiety, 26(10), 888-901. doi:10.1002/da.20600
  • Blyth, F. M., March, L. M., Brnabic, A. J., Jorm, L. R., Williamson, M., & Cousins, M. J. (2001). Chronic pain in Australia: A prevalence study. Pain, 89(2-3), 127-134.
  • Costa, A., Melina, F., Sansalone, A., & Iannacchero, R. (2015). Evidence based psychological treatments in pain management: A review of controlled and randomized trials about chronic headache, neuropathic pain and fibromyalgia. The Journal of Headache and Pain, 16(Suppl 1), A151.
  • Hayes, C., & Hodson, F. J. (2011). A whole-person model of care for persistent pain: From conceptual framework to practical application. Pain Medicine, 12(12), 1738-1749. doi:10.1111/j.1526-4637.2011.01267.x
  • Lynch, M. E., Campbell, F., Clark, A. J., Dunbar, M. J., Goldstein, D., Peng, P., . . . Tupper, H. (2008). A systematic review of the effect of waiting for treatment for chronic pain. Pain, 136(1-2), 97-116. doi:10.1016/j.pain.2007.06.018
  • McCracken, L. M., & Morley, S. (2014). The psychological flexibility model: A basis for integration and progress in psychological approaches to chronic pain management. J Pain, 15(3), 221-234. doi:10.1016/j.jpain.2013.10.014
  • Morley, S., & Williams, A. (2015). New developments in the psychological management of chronic pain. Can J Psychiatry, 60(4), 168-175.
  • NSW Agency for Clinical Innovation (ACI). (2013). Pain management programs – Which patient for which program? A guide for NSW Tier 3 and Tier 2 public health facilities providing pain programs. Retrieved from www.apsoc.org.au/PDF/Publications/20131216_ACI13-015-pain-programs.pdf.
  • Ohayon, M. M., & Schatzberg, A. F. (2010). Chronic pain and major depressive disorder in the general population. Journal of Psychiatric Research, 44(7), 454-461. doi:dx.doi.org/10.1016/j.jpsychires.2009.10.013
  • Pain Australia. (2010). National Pain Strategy. Retrieved from www.painaustralia.org.au/improving-policy/national-pain-strategy.
  • van Tulder, M. (2008). Conservative non-pharmacological treatment for chronic low back pain. BMJ, 337. doi:10.1136/bmj.a974
  • Vowles, K. E., McCracken, L. M., & O'Brien, J. Z. (2011). Acceptance and values-based action in chronic pain: A three-year follow-up analysis of treatment effectiveness and process. Behav Res Ther, 49(11), 748-755. doi:10.1016/j.brat.2011.08.002
  • Williams, A. C., Eccleston, C., & Morley, S. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev, 11, CD007407. doi:10.1002/14651858.CD007407.pub3

Disclaimer: Published in InPsych on June 2016. The APS aims to ensure that information published in InPsych is current and accurate at the time of publication. Changes after publication may affect the accuracy of this information. Readers are responsible for ascertaining the currency and completeness of information they rely on, which is particularly important for government initiatives, legislation or best-practice principles which are open to amendment. The information provided in InPsych does not replace obtaining appropriate professional and/or legal advice.