Accounting for pain beyond opioids

By: Michael Wolfson

The prestigious Canadian Academy of Health Sciences annual meeting last week in Vancovuer focused on chronic pain, and of course, the current catastrophe of opioid deaths was discussed.  But most of the discussion was broader: What are the biological mechanisms underlying chronic pain? What are the experiences of those suffering from chronic pain? How could Canada’s health care deal with chronic pain much more compassionately and effectively?

Pain is a difficult topic for Canada’s health care sector.  It can arise from many diseases, but not always. For example, arthritis in a joint can be visible on X-rays and not cause any pain; but it can also be so painful as to completely disable an individual. 

Pain is subjective so that sufferers can be dismissed as wimps or malingerers.  Science is only just beginning to find biological markers that can provide “objective” evidence that someone is really suffering from pain.

But there’s another problem: we don’t take pain into account when assessing where to invest health sector research and delivery dollars.

There are well-known adages that “you get what you measure” and “you cannot manage what you don’t measure.”  Canada’s health sector is unfortunately informed by misleading life expectancy and cause of death statistics. We pay much less attention to the kinds of health burdens borne while we are alive – like pain.  But we can change that.

Canada, as most countries, has a league table of the most important health problems in the population based on the disease written on death certificates.  But only recently, with the advent of high-quality population health surveys, do we now have good data on what makes us feel lousy while we are alive.

Cancer and heart disease are number one and two on the health problem league table because they are the most frequent causes of death.  Chronic pain does not register on this league table because it is generally non-fatal.

Pain is not a “disease” in the lexicon of the medical profession; it is more often considered only a symptom of some “real” disease.  And it does not have an obvious bodily location like heart or lung.

But what if we used another indicator: health-adjusted life expectancy or HALE?  This is like the usual life expectancy measure, with one major difference.  Instead of simply counting years as either alive = 1, and dead = 0, we count only years in full health = 1.  Periods of life spent being mobility impaired or in chronic pain would count somewhere in between 0 and 1.  In other words, for HALE, we count years in less than full health as positive, but not as highly as years in full health.

There are well-accepted ways to derive the numerical values to be given to living with this or that health problem.  If we do this, non-fatal health problems like chronic pain and mental illness rise dramatically in the health problem league table.  For example, the burden of arthritis (musculo-skeletal diseases) among women becomes their number one health problem, ahead of breast cancer, lung cancer and heart disease.

Instead of using diseases, we can also measure health problems defined in non-technical terms that everyone can understand: Can you see? Are you able to move around? Do you have problems remembering? Do you suffer from chronic pain?

While this switch from biomedically defined diseases to more ordinary vernacular descriptions of health problems may seem innocuous, it actually has profound implications for health care.  Doctors are generally trained to diagnose and treat diseases.  With clinical specialization, this orientation has become ever more siloed.  The cardiologist sees a patient in terms of their heart function, while a rheumatologist sees their joints.  They may only see the patient’s pain secondarily.

If we use HALE as our measure, and look at the impact of chronic pain from whatever source (or no obvious source at all), it is about four times as large as the two most common causes of death – heart disease and cancers.  If we allow our analysis to be more sophisticated to look also at the impacts of risk factors like tobacco smoking and obesity, chronic pain is still many times larger in its impact.

It’s time for our Health Ministers to start publishing and acting on the right indicators if they want to address the real experienced health burdens of Canadians.

Michael Wolfson is a member of the Centre for Health Law, Policy and Ethics at the University of Ottawa and a Contributor with based at the University of Winnipeg. He was a Canada Research Chair at the University of Ottawa. He is a former assistant chief statistician at Statistics Canada.