Chronic Pain Management and Canadian Public Health Insurance: Do We Need More Comprehensive Health Care?

Andrea Jones

Chronic pain is defined as ongoing pain that lasts longer than the typical period of time expected for healing, usually taken to be three months.[1] It can occur as a result of an injury such as back strain or an ongoing condition such as cancer, or it can have no known cause. Approximately one in five Canadian adults currently lives with chronic pain.[2] Shockingly, over half of those who report chronic pain also report suffering for ten years or more, indicating that a significant proportion of their life has been affected by this condition.[2] This multifaceted disorder is associated with significant disability and financial burden,[3] making effective and adequate treatment a top priority for patients, clinicians, and policy makers alike. This article will briefly discuss the treatment modalities for chronic pain and the lack of coverage for non–biomedical treatment options under Canadian public health insurance.

Conventional biomedical treatment options for chronic pain include prescription opioid analgesics and surgical intervention. While both of these practices remain important therapies for pain management, they are often not recommended as first–line therapy for mild–to–moderate cases.[4-6] Recommendations for first–line therapy vary according to the source, location, and strength of chronic pain symptoms, and they often include non–biomedical treatments.[4-6] For example, according to the 2009 guidelines for persistent, nonspecific low–back pain released by the National Institute for Health and Care Excellence (NICE), the recommendation for early treatment is one of exercise, manual therapy, or acupuncture; psychological and/or pharmaceutical treatment can also be included in the treatment plan, depending on the patient and the nature of their symptoms.[6]

Currently, treatments for chronic pain management included in Canadian public health insurance plans are largely restricted to the conventional biomedical treatment options provided by physicians. This is problematic, as several pain management guidelines recommend the use of psychological, behavioural, or less–invasive physical interventions, either on their own or in conjunction with conventional pharmaceutical treatment.[4-6] In Canada, patients are often required to pay out–of–pocket for less invasive, non–conventional treatment options, such as acupuncture, cognitive behavioural therapy, or customized exercise plans. This creates an issue of access, where not all patients can afford uninsured treatment, especially patients who are low–income or without private health insurance. The prevalence of chronic pain is high among people with low income and people who are work–disabled,[7] suggesting that the affordability of health care is a relevant issue in chronic pain management.

Currently in Canada, services for chronic pain management are fragmented across the public and private health systems, with an emphasis toward biomedical treatment within the public system. Patient demand for less–conventional treatment is evidenced by the very high use of complementary and alternative medicine by people with chronic pain.[8,9] In addition to this, under–treatment of chronic pain is a consistently–identified health care problem,[4,10] possibly due to a combination of physicians’ fear of over–prescribing and a lack of other publically–insured treatment options. Pain care advocacy groups have made multiple efforts to improve the treatment of chronic pain, and in 2014, the government of British Columbia invested one million dollars to support the training of patients and medical professionals in chronic pain management.[11] Hopefully such efforts already have and will continue to have a positive impact on the lives of those affected. However, if we consider access to chronic pain management a fundamental human right, and if we value efficacy over convention, a more integrated approach to public health care—one that includes coverage for a wider range of non–biomedical treatment options—is necessary.

REFERENCES
  1. Merskey H, Bogduk N, editors. Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. Seattle (WA): IASP Press; 1994. p. xi.
  2. Schopflocher D, Taenzer P, Jovey R. The prevalence of chronic pain in Canada. Pain Res Manag. 2011 Dec;16(6):445‑50.
  3. Stewart WF, Ricci J, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. J Amer Med Assoc. 2003 Nov 12;290(18):2443‑54.
  4. Jovey RD, Ennis J, Gardner–Nix J, Goldman B, Hays H, Lynch M, et al. Use of opioid analgesics for the treatment of chronic noncancer pain—a consensus statement and guidelines from the Canadian Pain Society, 2002. Pain Res Manag. 2003 Spring;8 Suppl A:3A‑28A.
  5. The American Academy of Pain Medicine. Use of Opioids for the Treatment of Chronic Pain. [Internet]. 2013 Feb [cited 2015 May 6]. Available from: http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf.
  6. National Institute for Clinical Excellence (NICE). Low back pain: Early management of persistent non–specific low back pain. [Internet]. 2009 [cited 2015 May 6]. Available from: guidance.nice.org.uk/cg88.
  7. Landmark T, Romundstad P, Dale O, Borchgrevink PC, Vatten L, Kaasa S. Chronic pain: One year prevalence and associated characteristics (the HUNT pain study). Scand J Pain; 2013 Aug 21;4(4):182‑7.
  8. Foltz V, St Pierre Y, Rozenberg S, Rossignol M, Bourgeois P, Joseph L, et al. Use of complementary and alternative therapies by patients with self–reported chronic back pain: A nationwide survey in Canada. Jt Bone Spine. 2005 Sep 07;72:571‑7.
  9. Metcalfe A, Williams J, McChesney J, Patten SB, Jetté N. Use of complementary and alternative medicine by those with a chronic disease and the general population—results of a national population based survey. BMC Complement Altern Med; 2010 Oct 18;10(1):58.
  10. Krames ES, Olson K. Clinical realities and economic considerations: Patient selection in intrathecal therapy. J Pain Symptom Manage. 1997 Sep;14 suppl 3:S3-S13.
  11. BC Ministry of Health. Investing $1 million in easing pain and giving hope [Internet]. 2014 Apr 28 [cited 2015 May 6]. Available from: http://www2.news.gov.bc.ca/news_releases_2013-2017/2014HLTH0033-000536.htm.

Jones A. Chronic Pain Management and Canadian Public Health Insurance: Do We Need More Comprehensive Health Care? UBCMJ. 2015: 7.1 (39).