Playing it safe

This issue sees the launch of a new series on diabetes that will span several upcoming issues of the Journal. In his introductory editorial, diabetes series guest editor Colagiuri (doi: 10.5694/mja14.01307) outlines key aspects that will be featured, highlighting an evidence–practice gap that is contributing to the burden of this condition in Australia.

In this issue, we also focus on patient safety. Hillman and colleagues (doi: 10.5694/mja14.01088) discuss the evolution of hospital rapid response systems, which are usually triggered by predefined deviations in patients’ vital signs. They suggest that system-wide engagement is likely to be critical to the success of such systems in improving patient outcomes.

New research from the Concord Medical Emergency Team (MET) Incidents Study (doi: 10.5694/mja14.00647) suggests that the disruption caused by staff leaving normal duties to attend MET calls did not result in major harm to other patients. In their single-centre study, MET call participants were interviewed to ascertain the rate of adverse events and incidents related to their diversion to cover MET calls. After 2663 MET call attendances, participants reported no adverse events and an incident rate of 213.7 per 1000 MET participant attendances, all of which were classified as “minor” or “minimum”. Although it is unclear if these findings can be extrapolated to other centres, they certainly provide some reassurance.

While patient safety is clearly top of mind, what about that of health care workers? Knott (doi: 10.5694/mja14.00681) candidly shares his experience of the aftermath of an adverse iatrogenic event that resulted in a patient’s death. He observes that in these situations, it is not uncommon for staff involved to be distressed afterwards and so become “second victims” of the event. He describes the lessons learnt from this particular instance and how a patient-centred approach was important to his own recovery process. Hills and Joyce (doi: 10.5694/mja13.00152) report on their exploratory, cross-sectional study of workplace aggression in Australian clinical practice, conducted as part of the third wave of the Medicine in Australia: Balancing Employment and Life survey. Of the responding clinicians, 27.2% reported experiencing internal aggression (ie, from co-workers) at work, while 67.6% reported experiencing aggression from external sources (eg, from patients) at work in the preceding 12 months. Adjusted and unadjusted analyses found both of these forms of aggression to be consistently negatively associated with job satisfaction, general life satisfaction and self-rated health. It was suggested that, in turn, such negative effects on clinicians’ wellbeing are potentially harmful to the quality and safety of patient care.

Hospitals clearly are a challenging environment for workers’ and patients’ safety, but safety in the community is also important, especially as outdoor recreational activities increase alongside the seasonal temperature. Howden and colleagues (doi: 10.5694/mja14.00567) report their novel study, which attempted to measure the rate of surfboard-related eye injuries in New South Wales over a 1-year period. Ten cases were reported by ophthalmologists, two of which were described as severe. The authors acknowledge that this was likely to have underrepresented the true rate of injury, and they advocate for the development of safety-enhancing modifications to surfboards. Protective eyewear, although unpopular with surfers, was also suggested as worthy of investigation.

While a beach full of goggle-clad surfers may be hard to envisage this summer, it is encouraging to hear of the efforts underway to make our hospitals and communities safer places to be.

The NSW Safe Sedation Project

To the Editor: About 300 000 episodes of procedural sedation occur annually in New South Wales public hospitals. Much of this sedation is supervised by non-anaesthetists.

Complications of procedural sedation are usually related to airway obstruction or depressed ventilation and can be life-threatening. Therefore, clinicians who administer sedation and care for sedated patients should have adequate knowledge and skills to assess, manage and provide rescue to these patients.

The Australian and New Zealand College of Anaesthetists has addressed the issue of procedural sedation since 1984 via policy statement PS09.1 Many specialist groups are cosignatories to PS09; however, its implementation has been incomplete.

Anaesthetists in NSW have long been aware of adverse outcomes from procedural sedation, and of reports from nursing staff who care for sedated patients and who feel poorly trained and unsupported for the tasks required.

The NSW Safe Sedation Project was established to support the safe provision of non-anaesthetist-administered intravenous procedural sedation. The project included development of minimum standards of care, a survey of NSW hospitals to confirm feasibility of the standards and raise awareness of PS09, and development of a toolkit including an audit tool.2

The minimum standards agreed to early in the project were (i) preprocedure: assessment and risk stratification of all patients who receive procedural sedation; (ii) intraprocedure: the constant presence of a dedicated clinician, to monitor and provide airway management for the sedated patient; and (iii) postprocedure: arrangements for monitoring the patient recovering from sedation.

The project team visited over 50 procedural departments in 17 hospitals in a range of metropolitan, regional and rural local health districts (LHDs) between 2012 and 2014. Some units reported underresourcing regarding direct anaesthetist availability, but this was the exception. There was considerable variation in the skill level of nursing staff caring for sedated patients (corresponding with scenario 1 in appendix 3 of PS09). This has also been observed by other authors.3

As project leaders, we recommend that consistent, high-quality education and training be developed and implemented for all clinical staff who regularly manage sedated patients. This training should be aligned with competency-based assessment.

We also recommend the development of hospital- or LHD-wide systems of governance and support for provision of sedation by non-anaesthetists.

To maximise the efficient use of highly skilled clinicians, hospitals and LHDs should consider developing processes that enable the triage of higher-risk patients to anaesthetists for sedation, and support appropriately trained and skilled non-anaesthetist sedation providers for lower-risk patients.

The Safe Sedation Project toolkit is available via the NSW Agency for Clinical Innovation website.2

Rapid response systems

Rapid response systems (RRSs) have become a routine part of the way patients are managed in general wards of acute care hospitals (Box 1).1 They are used in most hospitals in Australasia, North America and the United Kingdom and are increasingly being used in other parts of the world. They operate across the whole hospital and aim for early identification of seriously ill patients, at-risk patients and patients whose condition is deteriorating, using abnormal observations and vital signs (calling criteria). If any of these criteria are breached, the bedside nurse or doctor triggers a rapid response by clinicians who have the expert skills, knowledge and experience to initiate a coordinated response to any hospital medical emergency.

Traditionally, the most junior doctor and the bedside nurse were the first-line management team caring for patients in acute care hospitals. Interns were expected to assess and manage patients with deteriorating conditions, with little experience in the complexities involved in caring for more seriously ill patients. In the early 1990s, it started to become evident that many potentially preventable deaths and serious adverse events were occurring in acute care hospitals.2,3

Errors were ascribed to the system in which clinicians operated, rather than to individual incompetence.4 Hospitals operated in silos, where patients were admitted under a specialist in one area of medicine. This has certain strengths, such as the admitting doctor being ultimately responsible for the patient’s care. It had been a successful mode of operation for some time, but several changes have made it less effective.5 The population of patients in hospitals has shifted from relatively young patients with a single diagnosis to increasingly older patients with multiple comorbidities who undergo more complicated diagnostic procedures and treatment regimens.6 The needs of these older patients cannot necessarily be met by a specialist with limited experience outside his or her own area of expertise.7 The consultant, even if immediately available, may not have the appropriate skills to recognise and manage seriously ill patients requiring critical care interventions. Similarly, the consultant’s team of trainees, although more immediately available, may not have had the training necessary to manage seriously ill patients.

Patients with deteriorating conditions were not being recognised. More than 80% of those who suffered a cardiac arrest in hospital had documented deterioration in vital signs in the 8 hours before the arrest.8 More than 50% of those who died in hospital without a do-not-resuscitate order had severe antecedent derangements in vital signs.9 About 70% of patients admitted to an intensive care unit (ICU) from the general wards had vital sign abnormalities for at least 8 hours before being admitted to the ICU.10 Patients with deteriorating conditions were also managed suboptimally. A recent report from the United Kingdom found that the three most common reasons for potentially avoidable mortality in UK hospitals were mismanagement of deterioration (35%), failure of prevention (26%) and deficient checking and oversight (10%).11 RRSs have the potential to overcome all these problems.

Establishing a system around patient needs

It is common in hospitals for clinicians in one specialty to seek the opinion of clinicians in another specialty by requesting a consultation. Typically, this is not time critical. However, when a patient’s condition is deteriorating, the consultation must be as prompt as possible. For this to occur, an agreed way of defining at-risk patients is needed. This underpins the need for a standardised and objective set of calling criteria superseding the usual consultation process. Early intervention is more effective than waiting until a patient is so seriously ill that he or she requires expensive and invasive management in an ICU or, even worse, waiting until he or she suffers a preventable cardiac arrest or dies a preventable death.1

Vital signs

Before the widespread implementation of RRSs, there was little research into one of the most common interventions in acute care hospitals — the measurement of vital signs. Vital signs have been routinely measured and charted since Florence Nightingale used them for hospitalised patients in the Crimean War. The largest study on RRS effectiveness found that almost 50% of patients who died, had a cardiac arrest or were admitted to an ICU did not have vital signs measured before the event.12 Respiratory rate, the most accurate predictor of serious illness, is often not measured and, when it is measured, the measurement is often inaccurate.12,13 These findings have focused attention on the appropriate frequency for vital sign measurement, especially because hospitalised patients in general wards are at high risk of clinical deterioration.11 Deterioration in a patient’s condition can conceivably occur in the period during which vital signs are not usually measured.

Calling criteria

Vital sign abnormalities include: low systolic blood pressure (usually < 90 mmHg); high or low respiratory rate (eg, < 4 breaths/min or > 30 breaths/min); and abnormal pulse rate (eg, < 40 beats/min or > 140 beats/min). Potentially life-threatening observational abnormalities include seizures, airway obstruction and sudden decrease in level of consciousness. Staff concern is also an important criterion, empowering bedside nurses or doctors to seek timely assistance if they are worried about a patient who does not fit any other criterion. In mature systems, staff concern is a common reason for urgent assistance.14 Oxygen saturation abnormality, when available, is also a useful criterion.

Australian hospitals usually employ an RRS in which one calling criterion triggers a response. Hospitals in other countries may use scores, by adding vital sign abnormalities to trigger different levels of response.15 This could add a level of complexity and inaccuracy, and might encourage clinicians to focus on numbers rather than observation of the patient. It also excludes staff concern as a reason for seeking urgent attention.

Some centres are exploring the concept of encouraging family and visitors to trigger an urgent response. It is early days but, so far, there does not appear to be misuse of the system.16 Use of pathology results to identify patients at an even earlier stage in illness has also been explored.17 Although objective calling criteria are important, awareness of the RRS in itself can change an organisation’s culture, moving it from a traditional hierarchical and silo-based one to one with universal awareness that there are at-risk patients in a hospital and timely assistance is available.

The response

As with calling criteria, there is much variation in how organisations provide an urgent response. Some hospitals maintain separate cardiac arrest and rapid response teams. In the UK, it is common to have an outreach system, where nurses pre-emptively identify and manage at-risk patients across the hospital.18 A two-tiered system, where a member of the admitting team may be called for less serious abnormalities, is used in many organisations.19

Based on the evidence that hospitals suboptimally recognise and manage seriously ill patients,1–4,8–10 it is important to involve clinicians who have the appropriate training when caring for these patients, who often have complex needs. It is not surprising, therefore, that many rapid response teams use ICU staff.20 However, depending on the hospital setting, the urgent response could be provided by a doctor, nurse or paramedic, or by staff from any department in the hospital, as long as they have the appropriate skills, knowledge and experience.21

Other factors

Implementing an organisation-wide system such as an RRS involves challenging the way clinicians interact, bypassing entrenched hierarchies and constructing a system centred on patient needs. This requires more than standardised calling criteria and a rapid response (Box 2). All clinicians in the hospital must be aware of the system and support it. Similarly, senior administrators need to endorse and resource the system. An organisation-wide education program is required to teach staff how the system works and to empower people to call for assistance when needed.

It is also important to continually monitor the system and close the loop by making outcome indicators available to people at all levels of the organisation, especially to those responsible for and participating in the system.22 Some outcome indicators include cardiac arrest rates (which usually range between 0.5 and 6.0 cardiac arrests per 1000 admissions) and crude mortality rates. To make mortality rates more meaningful, patients with do-not-resuscitate orders are excluded. Data on cardiac arrests and deaths can be further refined by examining whether there were calling criteria that were not responded to appropriately in the 24 hours before the event. This gives insight into potential preventability. Delays in the rapid response can also be a useful indicator of the system’s effectiveness.21 Another important outcome indicator is the number of calls per 1000 admissions — an increase in the rate of calls is associated with reductions in mortality and cardiac arrest rates.23

Do rapid response systems work?

ICUs and RRSs are both systems for managing seriously ill and at-risk patients, but little robust research has been done to show the effectiveness of either. The general intuitive principle with such systems is matching the right people — with the right skills and knowledge — with the right patients at the right time.

It has been established that ICUs and RRSs identify and treat patients with a similar level of mortality risk.24 In other words, the boundaries between patients in general wards and patients in ICUs and high-dependency units (HDUs) are becoming blurred. One of the functions of an RRS is to act as a triage system, to identify sick ward patients who require ICU or HDU therapy. A 200-bed hospital with a 20-bed ICU will probably have less need for an RRS than an 800-bed hospital with a 10-bed ICU, as the more at-risk patients will already be in a highly monitored environment. In each hospital, RRS use also depends on patient casemix, average level of comorbidity and types of interventions undertaken.

Nevertheless, RRSs have been subject to evaluation. Not surprisingly, single-centre, before-and-after studies have almost universally shown significant reductions in outcome indicators such as mortality and cardiac arrest rates.25,26 Many of these studies were conducted by one or two “champions” who provided clinical leadership. The largest cluster randomised trial was underpowered and produced inconclusive results,12 possibly due to the contamination of control hospitals, less than satisfactory implementation and adherence, and variability in the effectiveness of implementation. Nevertheless, in a post-hoc analysis, the study did show a significant reduction in mortality in adult intervention hospitals.23 The largest meta-analysis on RRSs has shown 21% and 38% reductions in mortality and cardiac arrest rates, respectively, in paediatric hospitals, and a 34% reduction in cardiac arrest rates in adult hospitals.20 However, it is impossible to randomly assign patients to a group that receives early intervention by a rapid response team and a group that does not. Similarly, because of the almost universal uptake of RRSs in many countries,1 it is difficult to randomly assign hospitals. Other research methods must, therefore, be used. A recent study has shown a strong correlation between uptake of RRSs in New South Wales hospitals and reductions in cardiac arrest and cardiac arrest-related mortality rates, both of which decreased by about 50% over an 8-year period.27

Research now needs to shift to determining the most effective response teams, evaluating the sensitivity and specificity of calling criteria, assessing the cost-effectiveness of implementing RRSs, and defining the most effective RRS implementation strategies. Moreover, possible negative effects of RRS implementation — such as de-skilling of staff and putting excessive pressure on existing resources — need to be evaluated.

In the coming months, the Journal will publish a series of articles that explore how RRSs have changed our approach to patient safety, how RRSs have influenced end-of-life care in acute care hospitals, and how the use of cardiopulmonary resuscitation and cardiac arrest teams is changing.

1 Features of a rapid response system

Defines seriously ill patients, at-risk patients and patients whose condition is deteriorating using abnormal observations and vital signs (calling criteria)
Provides rapid response to seriously ill patients and those whose condition is deteriorating
Operates across the whole organisation
Is designed around patient needs
De-emphasises the usual hierarchies and interprofessional barriers
Provides rapid consultation by experts in critical illness

2 Strategies for maximising the impact of a hospital rapid response system

Engage the support of all doctors and nurses
Ensure that there is leadership and support from senior hospital executives
Implement strategies that promote hospital-wide awareness of the system
Ensure an urgent response to any staff concern, whether life-threatening or not
Ensure a 24/7 response by staff with appropriate skills, knowledge and experience
Build outcome indicators into the system and ensure targeted feedback of data
Conduct regular multidisciplinary meetings to discuss individual cases and outcome indicators

Depression and chronic pain

This is a republished version of an article previously published in MJA Open

Chronic pain and depression are frequently comorbid.1 The presence of depression in a patient with chronic pain is associated with decreased function,1 poorer treatment response2,3 and increased health care costs.4 An accurate diagnosis of major depression can be challenging in the setting of comorbid chronic pain. Antidepressants and psychological treatments can be effective and are best delivered as part of a coordinated, cohesive, multidisciplinary pain management plan. Here, we describe the current approach to the assessment and management of major depression in patients with chronic pain.

Biological basis of pain

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.5 Pain can be considered chronic when it persists for more than 1 month after anticipated tissue healing, or if it has been present for at least 3 of the previous 6 months.6 A differentiation is made between neuropathic and nociceptive pain, reflecting different pathological mechanisms, clinical features and treatments. Neuropathic pain is caused by a lesion or disease involving the nervous system. It may have signs of an altered pain response (allodynia, hyperalgesia) and is treated with agents targeting the nervous system abnormality. Nociceptive pain occurs as a consequence of actual or threatened damage to non-neural tissue. It reflects a normally functioning somatosensory nervous system and responds to general analgesics and anti-inflammatory drugs.

Chronic pain is reported by 18.6% of Australian adults. It occurs more commonly in women and those who are poorly educated, unemployed, older, disabled or in compensation systems.6 Common causes are joint arthritis, degenerative disc disease, traumatic injuries and various types of headache.7 Chronic pain can also occur as part of a generalised pain syndrome, such as fibromyalgia.

The emergence of chronic pain has been associated with a range of physical, psychological and social risk factors. These factors interact in complex and dynamic ways, often conceptualised within a biopsychosocial framework.8 Biological research has identified potential mechanisms for chronic pain in nociception, nerve conduction, regulation of spinal cord neurones, neuronal plasticity and gene expression.9 For example, there is evidence that neuroplastic change arising from poorly treated persistent pain can lead to sensitisation, defined as an “increased responsiveness of neurons to their normal input or recruitment of a response to sub-threshold inputs”.10 Neuroplastic change is one possible explanation for the altered pain perception, persistence of pain beyond tissue healing, and resistance to commonly used analgesics that are frequently found in chronic pain.

Pain and depression

The range of pain experiences is wide and varied. An individual’s response to chronic pain reflects characteristics of the pain and the person’s thoughts and behaviour developed during the course of the illness, which are subject to positive and negative reinforcement.11 The daily challenges of chronic pain that are commonly described include decreased enjoyment of normal activities, loss of function, role change and relationship difficulties.8 Uncertainty about ever being pain-free or the possibility of worsening pain are accompanied by feelings of anxiety, sadness, grief and anger. For some people, the burden of pain is difficult to manage and may lead to the emergence of a mental disorder.

Maladaptive responses to pain can, in themselves, worsen the pain experience and further impair function. The presence of catastrophisation, with excessive rumination about the pain, magnification of distress and excessive helplessness, is associated with a poorer response to pain treatments and greater disability.12 For example, in patients with low back pain, a cycle of excessive fear of movement leading to deconditioning, further worsening pain and further fear — termed fear avoidance — has been found to be more predictive of disability than pain intensity.13 Behaviour such as grimacing or groaning, reduced levels of activity, guarding against movement, and the use of protective devices is often linked with negative pain cognitions, and may also hinder recovery.

Major depression is the most common mental illness associated with chronic pain. High rates of generalised anxiety disorder, post-traumatic stress disorder and substance misuse have also been described.14 The lifetime prevalence of major depression in Australia is 11.6%,15 but it is 1.6 times higher in those reporting arthritis.15 In Canada, the prevalence of depression is three times greater in those with chronic back pain.16 In patients with chronic pain presenting for treatment, the prevalence of major depression is 30%–40%.17

There are several ways pain and major depression may be associated, one or more of which may be present in a single patient. First, the psychological and physical distress of persistent pain interacting with individual and social vulnerability may precipitate an episode of major depression.18 Common markers of vulnerability to major depression are a past personal or family history of depression, developmental deprivation, early loss of a parent, and substance misuse.19 Second, depression may be a precursor to, and in some way contribute to, the pain. Pain tolerance is decreased in major depression, and somatic preoccupation can be a prominent symptom, especially in older people. Of note, more than half of the patients presenting with major depression in primary care report some pain.19 In these circumstances, there can be a delay in making the diagnosis, especially when anhedonia predominates over lowered mood. Another proposed mechanism is that chronic pain is a subtype of depression.20 Serotonergic and noradrenergic neurotransmitters have been implicated in both conditions, and they share a clinical pattern of persistence beyond the precipitant. However, there is little other evidence to support this notion. The final way in which chronic pain and major depression may be associated is when both arise out of a common underlying process. This may be a neurological illness, such as multiple sclerosis, or one where the mechanism is not well understood, like fibromyalgia.

Assessment

An assessment of major depression in a patient with chronic pain should be done in conjunction with a pain assessment. A pain assessment characterises the pain, identifies prominent cognitions and behaviour, differentiates nociceptive and neuropathic pain, and determines the impact of pain on function. A comprehensive assessment may include input from a range of disciplines, including pain medicine.

The diagnosis of depression in patients with chronic pain is made more complex by an overlap between depressive symptoms and those relating to the comorbid physical illness and pain (see also Olver and Hopwood, Depression and physical illness).21,22 According to the Diagnostic and statistical manual of mental disorders, 4th edition, text revision (DSM-IV-TR), a diagnosis of major depression requires depressed mood or diminished interest or pleasure over 2 weeks, with additional somatic symptoms (sleep disturbance, fatigue, diminished ability to think, weight disturbance) and cognitive symptoms (worthlessness, guilt, suicidality), all leading to significant distress or dysfunction.23 However, most patients with chronic pain describe decreased initiative,18 anhedonia,18 and sleep and appetite disturbance. Several approaches may be used to overcome this diagnostic overshadowing, each representing a different balance of sensitivity and specificity.24

First, the inclusive method allows for all symptoms to be included in making the diagnosis, even if they could be explained by physical illness or pain. This approach has the advantage of simplicity and reliability, but can result in overdiagnosis of major depression.

Second, the exclusive method requires that somatic symptoms are not used, leaving the cognitive symptoms from which to make the diagnosis. Patients with chronic pain and depression are more likely to describe increased sadness, reduced self-worth, lack of meaning and suicidality than those with pain alone,18 giving support to an exclusive approach. The exclusive method deals well with diagnostic overshadowing but at the cost that some cases, including in patients with more severe forms of depression manifest in somatic complaints, might be missed.

Third, using the substitutive method, somatic symptoms of depression are replaced with additional cognitive or affective symptoms. These may include hopelessness, pessimism, irritability, tearfulness, feeling punished, or social withdrawal. There is no consensus on which symptoms can be used as substitutes, nor the total number required.

Finally, the aetiological approach requires judgement by the clinician as to whether the symptoms are related to the physical illness or the depression. This method is supported by the DSM-IV-TR,23 but has the disadvantage of the reduced reliability implicit in making this judgement.

No one approach has a clear advantage over the others. In some cases, the same conclusion will be reached regardless of the method, as in a patient with clear mood change, rumination, pessimism, hopelessness, guilt, low self-worth, and a depressed affect on mental state examination. When the diagnosis is less clear, as in a patient with a fluctuating affect, less prominent cognitive symptoms or marked somatic symptoms, interviewing collateral historians, such as the patient’s family, to determine a clear and persistent change in mental state over time can be useful.

Management

The management of major depression in patients with chronic pain should occur as part of a coordinated approach to pain management, with attention to relevant psychological processes and social issues. In addition to specific interventions, pain management involves identifying and establishing shared treatment goals, collaborative multidisciplinary care and a mutual understanding of the different practitioner roles and responsibilities.

Pharmacological treatment

Research into the pharmacological treatment of major depression in patients with chronic pain has predominantly focused on tricyclic antidepressants (TCAs). TCAs have analgesic properties independent of their antidepressant effect.25 The presumed mode of analgesic action is through enhancing descending spinal noradrenergic and serotonergic inhibitory neurones.26 The doses used in analgesic studies27 and in pain medicine (10–50 mg) are lower than those used for depression (100–200 mg).28 Analgesic studies have demonstrated decreased depressive symptoms alongside reductions in pain, but the treatment of major depression has not been established at these doses. If TCAs are used to treat major depression, antidepressant doses are required.28 Higher doses lead to increased side effects, including sedation, blurred vision, orthostatic hypotension, falls and an increased risk of delirium. Concern about cardiac toxicity, especially in overdose, has led to caution around the use of TCAs as antidepressants. In patients without cardiovascular disease and in whom concerns about self-harm are low, TCAs still have a role, especially when other antidepressants have not been effective. The secondary amines nortriptyline and desipramine are better tolerated than imipramine and amitriptyline in medically ill patients29 and may also be preferable in patients with pain.

A smaller body of research exists in relation to the newer antidepressants and their analgesic properties. Of particular interest are the serotonin–noradrenaline reuptake inhibitors (SNRIs), given their similarities to TCAs. Duloxetine, an SNRI with balanced inhibition of serotonin and noradrenaline reuptake, is effective for both neuropathic30 and nociceptive pain31 — an effect independent of reductions in depression or anxiety. The United States Food and Drug Administration has approved duloxetine for the treatment of fibromyalgia and painful diabetic neuropathy at a dose of 60 mg daily.32 Common side effects of duloxetine are nausea, vomiting, constipation, dry mouth and insomnia, but these are often mild and transient. The evidence for venlafaxine, in which serotonin reuptake inhibition predominates, especially at low doses, is less robust. Case reports33 and some study evidence34 suggest potential for analgesic activity in neuropathic pain at doses of around 75 mg.

The management of comorbid major depression and chronic pain with antidepressants requires clarity around the aims of treatment. TCAs and venlafaxine at analgesic doses are subtherapeutic for major depression. Combining TCAs with selective serotonin reuptake inhibitors (SSRIs) has the potential to induce a serotonergic syndrome. Although there is evidence for response of major depression to duloxetine at doses of 60 mg, some patients require doses of 120 mg.35 To treat major depression effectively, antidepressants need to be used at therapeutic doses for at least 4 weeks, before increasing to higher doses or changing to another agent. SSRIs, which have limited analgesic effect, are often used as first-line treatment of major depression. Among these, escitalopram and sertraline are most efficacious and best tolerated,36 with escitalopram having a low propensity for drug interaction through induction of liver enzymes. Even with optimal treatment, however, antidepressants may not be effective in inducing remission of major depression, especially in the context of severe and prolonged pain.37

Psychological interventions

Psychological therapies are used to treat major depression and reduce depressive symptoms in patents with chronic pain. The most robust evidence for their use in the treatment of major depression is derived from randomised controlled trials involving the general population and patients with other medical comorbidities. In a landmark study, 12 sessions of standardised and adherent cognitive behaviour therapy (CBT) or interpersonal therapy were found to be equivalent to imipramine (200 mg) and more effective than placebo or supportive therapy in treating major depression.38 A study of CBT and antidepressant therapy in patients with multiple sclerosis showed lower rates of major depression in the two treatment groups, compared with the group receiving treatment as usual.39 The negative cognitions challenged in CBT for major depression relate to the world (pessimism), the future (hopelessness) and the self (low self-worth), and the focus of behaviour change is withdrawal and cessation of pleasurable activities. The aim of CBT for major depression is remission and recovery.

Psychological therapies are effective in reducing depressive symptoms in patients with a medical illness40 or chronic pain.41 CBT in patients with chronic pain challenges maladaptive pain cognitions and behaviour, such as catastrophisation and fear avoidance. The aim of CBT in regard to chronic pain is symptom reduction and functional improvement, rather than complete pain relief. Within a multidisciplinary pain program, these methods can increase perceived control and decrease catastrophising, leading to a decrease in pain and depressive symptoms and improved function.42 Techniques that address change, loss, relationship difficulties, acceptance and self-regulation may also be useful.43 Pharmacological and psychological treatments are commonly combined, an approach that has been shown to be effective in the management of depressive symptoms in patients with musculoskeletal pain in primary care.44

Conclusions

Major depression is common in patients with chronic pain. Making the diagnosis can be difficult and is best done as part of a wider pain assessment. Depression is treated pharmacologically and psychologically, although treatment efficacy can be reduced in patients with severe and prolonged pain. Collaboration with other treating clinicians and specialist advice are often useful, especially in complex cases. Despite these challenges, successful treatment of major depression will reduce pain and improve function and quality of life for patients with chronic pain.

A personal reflection on staff experiences after critical incidents

The effects of adverse iatrogenic events extend beyond patients and families to health care staff and organisations

Errors are common during the delivery of complex care in the Australian health care system.1 Adverse iatrogenic events (critical incidents) resulting in patient harm or death may be the most distressing for all involved. Many of these errors are preventable, but investments in programs to prevent health care-related adverse events have had varying success.2,3

After critical incidents occur, emphasis is rightly placed primarily on the immediate, interim and long-term care of the patient and family. At the same time, health care organisations must also manage the staff involved in the incident and ensure appropriate responses to reduce the risk of future events.

This is a personal account of how individual health care workers and organisations may respond, and then recover, after a devastating critical incident. Possible ideal responses after a critical incident and preventive workplace cultures are also considered.

Personal reflection

During my intensive care medicine training, I was involved in a team failure that resulted in the injury and subsequent death of a young family man due to a medical intervention. While I was not directly responsible, I was part of the team responsible for this lethal injury. My team members and I learned many profound and lasting lessons from that terrible day. A culmination of interhospital and intrahospital system problems and failures in team planning and communication contributed to this man’s death. Over subsequent years, these factors were explored and acted on at personal, departmental, hospital and coronial levels. I met the man’s family on the last day of the inquest. I promised them that I would incorporate what I had learned into my practice and share it with others to try to prevent similar tragedies. This short insight into my journey through the aftermath is part of that promise.

Immediately after the critical incident, I experienced many personal, emotional and professional challenges.4 When the patient subsequently died from his treatment injuries, these feelings were exacerbated by the knowledge of the devastating financial and social outcomes for his family. I believe my team members underwent similar experiences at different times after the event, before the inquest and beyond. Due to different shifts and roster rotations, ongoing clinical workload and our varied coping strategies, I did not have many opportunities to discuss these experiences with other members of the immediately involved team.

Sharing my experiences of the event and its aftermath with others in the hospital enabled me to make sense of the situation and to identify meaningful action for my own personal and professional recovery.5 Many of my experiences matched those described by Scott and colleagues in their six-stage adverse event recovery process: 1) chaos and accident response; 2) intrusive reflections phase; 3) restoration of personal integrity; 4) enduring the “inquisition”; 5) obtaining emotional first aid; and 6) moving on.6 My recovery began with the realisation that this must be a fully grasped, lifelong, patient-centred learning and quality improvement opportunity.

I felt many of the expected emotional responses, in fluctuating intensity, including self-critical thoughts, loneliness, shame, guilt, sleep disturbance, and profound and hurtful feelings of professional insecurity. I witnessed other staff members experiencing varying levels and periods of functional impairment in the workplace. I managed to avoid serious workplace difficulties7 by using institutional, peer and family supports — by seeking company, participating in open disclosure discussions and quality review sessions, and accessing mentors. As a result, I did not require professional treatment or sick leave.

I received feedback about my personal and professional performance by discussing, listening and reflecting during and in between these opportunities — often with solemnity, sheepishness, anger, frustration, trepidation, grief and dismay. I had periods of deep and painful reflection. I also had opportunities for open and non-judgemental discussion in both private and workplace settings with my own family and friends and with colleagues from different professions and disciplines. At the same time, ongoing risk management, quality improvement and medicolegal processes enabled further clarification of “what happened”. In retrospect, I am grateful for the structured processes that supported my psychological work in understanding the incident.

Others in my team had different needs, and some appeared to experience differing levels of support from the health care organisation. Many resorted to relying on the informal support of family, friends and peers when the structured organisational support did not meet their needs.

Organisational response

The organisational response to this critical incident was multifaceted and prolonged. Initially, within the first 24 hours, the staff involved completed written statements of their personal understanding of events. This was followed by a team debriefing led by senior staff. Meetings involving the wider departmental staff, mentors and administrators took place over the ensuing days, weeks and months, with later formal departmental presentations. Further recapping with the legal team around the inquest hearing was highly valuable.

The patient’s family were engaged in open disclosure processes from the time of the event. They were regularly informed of the patient’s progress before his death and the ongoing hospital responses. Departmental responses included a root-cause analysis to determine all contributory factors. “Human factors” were considered predominant reasons.

The departmental nursing and medical leaders and clinical governance and medicolegal teams conducted a detailed review and improvement of equipment, policies, guidelines, processes and procedures. Case presentations and reviews at quality and safety sessions and hospital grand rounds disseminated knowledge gained and lessons learned from the incident. Reports were also prepared for the insurers and medicolegal department. Staff orientation, induction and training processes were changed to include multidisciplinary crisis resource management, to improve the staff’s technical and non-technical skills.

My active and passive involvement in these processes, and associated formal and informal dialogue, assisted with my understanding of the event.

“Moving on” to future prevention

Emerging literature about the emotional and professional burdens carried by health care staff after critical incidents describes the patient and family as “first victims” and the staff involved as “second victims”.8 These terms seem pejorative, negative and unhelpful, yet I cannot find suitable alternatives. This terminology derives from the perceived gap between the support provided to staff by the employing health care organisation and the support that staff actually require, particularly when compared with the support (rightly) offered to the aggrieved patient and family.

A thematic analysis of interviews with Scandinavian multidisciplinary health care staff after adverse events explored their responses in detail.7 The range, depth and variability of emotional responses were confirmed, along with significant self-reported changes in professional performance and self-confidence. Variability in each individual’s post-event personal and professional needs was also noted. The authors recommended coordinated, structured, transparent and systematic organisational responses for patient and family support, coupled with personal and professional support for staff.

After this critical incident, my personal recovery continued through the interaction of individual and organisational responses. I pursued external learning to acquire the knowledge and skills required to prevent further such incidents in my own practice. As such, I do not believe I am a second victim. Rather, I am a member of a responsible team. We have learned and helped others by conceptually placing the bereaved family at the centre of our own recovery. This long and challenging process demonstrates the power and importance of patient-centred quality and safety initiatives. After critical incidents occur, structured immediate, interim and long-term care of patients, families and staff is needed to enable enlightened improvement. Health care staff may already be carrying a disproportionate and under-recognised mental health burden and may need more attention than is often given.5,9

Developing health care organisations to be high-reliability organisations (HROs) may help to reduce second-victim scenarios.10–12 HROs are characterised by their ability to manage complex, time-pressured and demanding sociotechnical tasks while avoiding catastrophic failure. Their organisational performance is often matched by an ability to expand capacity in a crisis. This is achieved through planning for variability in human performance by accepting the possibility of failure. HROs have evolved multiple redundant preventive and adaptive systems that integrate safety, quality and workplace learning. Any error is reported and proactively examined, and prevention strategies are subsequently developed and integrated into the workplace systems. These active system responses are said to cause the “dynamic non-event” of critical incident prevention.10

However, even with the best preventive systems, critical incidents will still occur. After a critical incident, it is essential for health care staff to seek help for themselves, in addition to the support provided to the patient and family. Constructive and supportive incident responses for patients, families and staff must be activated and maintained over months to years. Lessons learned must be integrated into workplace systems. I implore readers to become proactive agents of personal and institutional change for building resilience and reliability, in honour of your patients. Remove the need for anyone to be labelled a second victim.

Unrelieved pain: are we making progress? Shared education for general practitioners and specialists is the best way forward

The National Pain Strategy is driving improvements in pain management, but greater impetus is needed

One in five people are afflicted by chronic pain in Australia, with many experiencing severe disability.1,2 Such disability is strongly correlated with greater use of health resources and increasing reliance on disability support payments.3 Low back pain is now the number one cause of years lived with disability in Australia and globally.

A key Australian study was the first to report that people with chronic pain who use “active” self-management strategies experience markedly reduced disability, compared with those who rely on “passive” treatments such as medication and massage.2 A wide range of other effective treatments and a recommended treatment framework are detailed in the National Pain Strategy (NPS). However, a nationwide study of access to pain services reported major inadequacies, with average wait times of 150 days,4 and a Canadian study reported adverse outcomes of waiting for access to treatment for chronic pain.5

The widespread prescription and misuse of opioids in chronic pain, often associated with adverse events, further highlights the need for improved access to multidisciplinary services.

An article in the Journal in 2012 called for prioritisation of chronic pain management to address the lack of equity of access, compared with other chronic conditions.6 The moral imperative of this is evidenced by the millions of people worldwide who suffer unnecessarily with unrelieved pain7 and the financial costs in Australia of more than $34 billion annually8 including the costs of lost workforce participation, forced early retirement and numerous other financial burdens.3,8

Progress is now being made to address this including, but not limited to:

federal government recognition in 2005 of pain medicine and palliative medicine as independent medical specialties;
establishment of the Faculty of Pain Medicine (FPM), with qualifications administered by five specialist bodies — Australian and New Zealand College of Anaesthetists, Royal Australasian College of Surgeons, Royal Australasian College of Physicians, Australasian Faculty of Rehabilitation Medicine and Royal Australian and New Zealand College of Psychiatrists;
creation of world-leading education and training resources in pain medicine administered by the FPM, postgraduate pain education programs provided by the Pain Management Research Institute, University of Sydney, and recognition of pain medicine as an independent academic discipline by the University in 2012;
development of the NPS by 150 health professional and consumer organisations, and approval of the NPS by consensus at the National Pain Summit (2010); and
the formation in 2011 of advocacy body Painaustralia (http://www.painaustralia.org.au) — to work with state and federal governments and health care and consumer stakeholders to facilitate its implementation.

The initial focus of state and territory governments has been to consolidate capacity in tertiary multidisciplinary clinics and expand access by establishing regional pain centres. Fourteen new centres are now operating in regional areas of New South Wales, Victoria and Queensland. With wait times for tertiary services still unacceptably long, many tertiary pain centres are providing education and training for general practitioners and allied health professionals in their area to support more effective intervention at the primary care level, as recommended in the NPS (Box). Web-based resources for consumers are now available (http://www.aci.health.nsw.gov.au/chronic-pain and http://painhealth.csse.uwa.edu.au), with support groups in the community including a pain helpline run solely by volunteers.

With the high percentage of GP consultations involving a person with chronic pain, and considering rising concerns about over-reliance on pain medications including opioids, there is a need to ensure that pain management education and training is accessible to all GPs. A lot of effort and resources are now being applied to this critical area of need in an effort to address this serious community health problem.

The “gamebreaker” lies in the development of multidisciplinary teams of GPs, nurses and allied health professionals including physiotherapists, clinical psychologists, occupational therapists and pharmacists — all with training in pain management — capable of working in an interdisciplinary manner to assess and treat physical, psychological and environmental factors in patients with chronic pain. Recognising the need for early intervention, several Medicare Locals have established innovative pain programs in primary care. A trial of such a model in Western Australia showed significantly reduced wait times at tertiary pain centres.9 There is an opportunity for such programs to be expanded into other areas as Medicare Locals transition into Primary Health Networks.

It is encouraging to note that seven GPs have now qualified as Fellows of the FPM, with another seven at various stages of training. Web-based resources have been developed for GPs and allied health professionals including:

gplearning (http://gplearning.racgp.org.au/Home/index.aspx), a resource developed by the FPM and the Royal Australian College of General Practitioners with funding from Bupa Health Foundation;
a range of programs provided by the Pain Management Research Institute;
a postgraduate degree program in pain management at the University of Sydney (http://sydney.edu.au/medicine/pmri/education/postgraduate/index.php); and
practical resources developed by the NSW Agency for Clinical Innovation Pain Management Network (http://www.aci.health.nsw.gov.au/chronic-pain).

Additional funding is urgently required to meet the nationwide demand for enhanced skills and capacity. Another barrier to progress is the restrictive access to Medicare funding for allied health services.

The NPS proposes a “seamless” two-way movement of patients between tertiary, secondary and primary care, with most patients having access to assessment and treatment at primary care level, and only those with the most complex pain conditions being referred to tertiary pain centres or other specialists (eg, rheumatologists or neurologists) as appropriate. The NPS envisages that such specialists would welcome the option of referring laterally to pain medicine specialists when, despite their best efforts, chronic pain remains unrelieved.

Although early intervention and seamless referral and service integration is common practice for some chronic conditions (eg, diabetes or stroke), there is surprisingly little data about the effects of formal cooperation between specialists and GPs managing patients with chronic pain.10

In stroke treatment, for example, outcomes for patients who had a formal care meeting at discharge (by teleconference if necessary), between the tertiary inpatient stroke team and community health professionals, were evaluated and compared with outcomes for patients who did not receive such a process.10 For those patients discharged after a care meeting, the benefit was a negotiated care plan with a 50% increase in likelihood of independent living compared with patients who did not receive such a process. A similar process for people with chronic pain would ensure optimum management of their condition while minimising the likelihood of patients re-presenting for treatment or hospitalisation.

Experience suggests it would be beneficial if educational materials were shared, with a pain management module available to all medical specialties. Joint multidisciplinary educational meetings on all forms of pain have already been held on multiple occasions. This gradual process of sharing knowledge is greatly enhanced by face-to-face discussion, as recommended by J J Bonica, the founding father of multidisciplinary pain medicine.11

Proposed model of care: multidisciplinary pain services at tertiary, secondary, primary and community care levels*

GP = general practitioner. * Reprinted with permission from Painaustralia. Vertical and horizontal arrows show that patients may be referred in both directions for continuing care.

Cost of best-practice primary care management of chronic disease in a remote Aboriginal community

The health of Australian Aboriginal and Torres Strait Islander people is very poor, and their access to primary care is inadequate, especially in remote areas.1–3 Prevalence of and mortality from type 2 diabetes (hereafter diabetes) and chronic kidney disease (CKD) are extremely high in remote Aboriginal communities in the Northern Territory.4 Chronic disease is responsible for 80% of the mortality gap between Indigenous and non-Indigenous Australians, with diabetes accounting for 12%.5 For all Indigenous Australians, the self-reported prevalence of diabetes is more than three times, and the incidence of end-stage CKD six times, the non-Indigenous rates.3 In remote Aboriginal communities in the NT, CKD prevalence is up to 25% of the population,4 or 46% of adults.6 Diabetes prevalence is in the order of 13%7 to 16%4 of the population, or up to 29% of adults.6 Both conditions are major contributors to cardiovascular disease, the greatest single contributor to the mortality gap.5

The origins of the chronic disease epidemic in Indigenous populations and, more broadly, the health gap are complex,3,6 and actions addressing both the social determinants of health3,4,7,8 and systematic primary clinical care6,9 are needed. In this study, we focused on the need for systematic clinical care, which is essential to reduce complications and delay the progression of diabetes and CKD.6,9

The rate of avoidable hospitalisations, a key marker of access to and effectiveness of primary care, is highest in remote communities.10 Australian and international evidence shows strong primary care systems result in better health outcomes, lower rates of avoidable hospitalisations, avoidance of dialysis, and significant cost savings.9–13 Many hospitalisations for complications of diabetes and CKD can be avoided through systematic primary care treatment, with significant medical cost savings.10,13–15 However, there are few estimates of the resources required to sustain primary care management of these conditions.

Particular difficulties for remote primary care include isolation, long distances to services, understaffing and a high turnover of clinical staff.16 Remote health care also requires special skills in chronic disease management, acute care, public health and intercultural communication.13,14,16,17

Our study was initiated by an Aboriginal community controlled remote health service because, despite its own perceptions of competent staff and clinical systems, staff still struggled to satisfy existing clinical protocols within given resources. The service received funding primarily from the then federal Office for Aboriginal and Torres Strait Islander Health and the then NT Department of Health and Families. Other sources included Medicare and a small university research grant. The aim of our study was to estimate the resources required by a remote health service to optimally manage diabetes and CKD — with adherence to the local Central Australian Rural Practitioners Association Standard Treatment Manual (CARPA STM) guidelines15 and with full population coverage.

Methods

The study took place between July 2010 and May 2011 in a remote Central Australian community. The methods were adapted from the models of care health service planning approach18 and an earlier NT cost study.10 Using the models of care approach, Segal and colleagues18 began with local best-practice protocols and estimated the staff time required to complete each of the recommended tasks for a given population. The population health status was assessed and the best-practice health care tasks required for that population were defined for each health profession involved. The time required per patient per year for each task was then determined, and the health care staffing resources then calculated for the population. Zhao and colleagues10 used an analogous approach to estimate the total operating costs of a “reasonably efficient” remote Aboriginal health service. Population needs were defined in terms of the CARPA STM protocols.15 The time estimate given in the definition of each linked Medicare Benefits Schedule item was used in quantifying the population’s staffing needs.10

The target population was resident adults (> 18 years of age) with diabetes or CKD. Best practice was defined in terms of the CARPA STM protocols.15 These protocols are used by all NT primary care providers: government clinics and Aboriginal community controlled health services.19 The tasks recommended by the CARPA STM include history taking, health promotion, education, physical examination, biochemical investigations and prescription of medication.15

First, prevalence of diabetes and CKD was estimated using the health service electronic health record, which represents not only patients presenting for diabetes and CKD management but also those identified in community screening. Prevalence at multiple levels of severity was estimated for both conditions. For CKD, levels of severity were stages 1–5 (estimated glomerular filtration rate range, > 90 [stage 1] to < 15 mL/min/1.73 m2 [stage 5]), with early CKD defined as stages 1–3. For diabetes, early was defined as non-insulin-treated and advanced was defined as insulin-treated. This enabled us to calculate, at the community level, the total annual number of diabetes and CKD care tasks recommended by the clinical protocols.

Second, semistructured interviews informed two aspects of the study. Clinicians were asked to estimate the time required for each protocol task, as well as any unremunerated out-of-hours time essential for the chronic disease management program. Clinicians’ descriptions of their role in chronic disease care helped to structure the final staff-funding model and also to identify other barriers to best-practice care.

Third, the daily work and chronic disease consultations undertaken by a cross-section of clinicians were directly observed in a detailed time-and-motion study. We measured the time taken by each clinician for each task defined by the relevant CARPA STM protocol. We then used a combination of these observations and interview data to estimate an average time for each item (such as measuring blood pressure or discussing diet). Supplies were itemised for each protocol and costed using the clinic’s supply orders or representative prices.

Fourth, financial records provided clinicians’ wage rates and administrative fixed costs. The wage rates, together with the estimates of time-per-task and annual community care requirements, were used to calculate the total cost of clinical staffing for primary care of diabetes and CKD.

We considered costs that, while non-clinical, are part of the overall cost footprint of diabetes and CKD care. Using data from direct observation of clinicians’ workdays, we estimated the proportion of total clinical time spent on diabetes and CKD. This proportion was then applied in a top-down fashion to the health service’s non-clinical costs, so that part of the cost of clerical staff and clinic vehicles was attributed to diabetes and CKD. These data collection and cost estimation methods are summarised in the Appendix.

Finally, we compared the estimated 2009–10 expenditure on diabetes and CKD with the projected annual expenditure using our best-practice model, reflecting full protocol compliance. For this, we assessed the level of clinicians’ adherence to the guidelines using the One21seventy health record audit tool, which is widely accepted in Indigenous health services in Australia and is based on the CARPA STM protocols.20 Per capita figures were calculated as total staff hours required for tasks specific to each group (eg, staff hours per patient per week to manage insulin treatment) divided by the number of patients with CKD or diabetes.

We distinguished between costs met out of the health service budget and expenses met directly by the federal and NT governments and other agencies. Examples of the latter are medications provided free to Indigenous patients under s 100 of the National Health Act 1953 (Cwlth), and visiting allied health services. The increased cost of such items in our model of care was separated from any additional funding needed by the health service to provide that model.

For comparison with the study by Zhao et al we adjusted the 2003–04 NT-wide figures for inflation occurring between financial years 2003–04 and 2009–10 (using the Consumer Price Index for health care in Darwin), and only included comparable aspects of our study (eg, insulin treatment was excluded).10,21

Approval was received from the remote community’s health board and the Central Australian Human Research Ethics Committee (ref: 2010.08.07). Written consent was obtained from all individual participants. Verbal and written feedback was provided to the health board at the conclusion of the study.

Results

In this remote community with a population of 542, 519 (96%) were Aboriginal.22 Of the 297 adults, 74 (25%) had diabetes and 86 (29%) had CKD; 45 (15%) had both conditions. Thirty-one adults (10%) had CKD stages 3–5. Of the 74 adults with diabetes, 13 (18%) were prescribed insulin.

The clinic was staffed by four Aboriginal health workers (AHWs), three remote area nurses (RANs), a general practitioner, a chronic disease educator (CDE) and an exercise physiologist. Twelve staff interviews were completed, and 14 workdays and seven clinical consultations were directly observed.

Quarterly chronic disease checks with an AHW or RAN were recommended for most patients with diabetes or CKD. A GP reviewed clinical findings and investigations, prescribed medication where necessary, and oversaw treatment planning. A full-time CDE educated individual patients and groups and managed insulin treatment. Interviewed staff identified education as crucial for patients’ control of their chronic disease. Locating patients in the community and delivering and explaining their medications were also a significant part of clinicians’ work. According to the medical record audit, 75% of all recommended protocol tasks for diabetes management and 79% for CKD were completed in 2009–10. Based on 2009–10 staffing, our model results in 29% of total clinical hours being used for diabetes and CKD care.

The total projected annual primary care cost of clinical management of diabetes and CKD management with full adherence to the protocols for all patients would be $900 792 (Box 1). On average, the annual cost per patient would be $7856, ranging from $4062 (for people with previously diagnosed early CKD without diabetes and without high cardiovascular risk) to $15 241 (for people with stage 5 CKD and advanced diabetes, with a recent diagnosis of either condition) (Box 2). Including only the costs met through the health service-allocated budget, the projected cost to the centre would be $645 313, or $5628 per patient on average, based on estimated total annual direct clinical staff hours specifically for diabetes and CKD of 4226 hours, or 2.37 full-time equivalents. (The difference between the cost to the centre and the total projected annual cost consists of costs met directly by other sources, including the federal and NT governments, rather than through the health service budget.) Expenditure in 2009–10 by the remote health service for diabetes and CKD care was estimated at $446 585, or $3895 per patient (Box 1). The health service would thus require an additional $198 728 (ie, an additional $1733 per patient) for best-practice management of diabetes and CKD. Overall funding received by the health centre in 2009–10 was $3413 per patient.

Interviews with staff identified a number of other barriers to optimal care. The high turnover of RANs necessitated frequent intensive orientation and teaching for new staff. The clinic was also rarely fully staffed. On-call night work, cross-cultural communication and cultural differences can present difficulties for RANs. AHWs may face a conflict of duties and values between the community and the health centre and a heavy responsibility in the role. A high acute caseload and the reticence of many patients to attend checks, for reasons including low health literacy and long waiting times, also hinder adequate management of chronic disease. There is a perceived need to allow more time for clinicians and patients to build relationships and for community-building work.

Discussion

Our study identified a high prevalence of diabetes and CKD in a remote community. As this is the community’s only clinic and the community health screening coverage is high, the clinic-based prevalence approximates population prevalence and is consistent with other remote community studies.4,13

This service is relatively well funded compared with other NT primary care services. Expenditure in 2009–10 was $3413 per capita per annum. The mean per capita figure for NT Government remote clinics for 2011–12 was $2329. This service has a higher than average compliance with the protocols for CKD and diabetes (77%, compared with the territory-wide figure of 73% for clinics participating in the One21Seventy audit). In response to low health literacy and patient mobility, the clinicians engage in very active outreach, health education and opportunistic screening. Most remote communities do not employ a CDE or exercise physiologist.

Despite these positive factors, 2009–10 expenditure was insufficient to provide optimal management by a margin of 44%, or an average of $1733 per patient with diabetes or CKD. Quantitative data were consistent with clinicians’ perceptions at interview that additional staff members were required to work with the CDE and AHWs to adequately meet community needs. Additional staff could increase the crucial quarantining of AHWs’ and RANs’ chronic disease care time from acute care time, possibly contributing to enhanced retention of staff. It would also allow greater allied health coverage, increasing exposure of patients to consistent health messages, and additional informal staff education.

The costs calculated in our study were higher than the inflation-adjusted (2003–04 to 2009–10) NT remote community estimates produced by Zhao et al.10,21 Possible reasons include the conservative estimates by Zhao et al of clinical time needed in remote health services for chronic disease care and staff training, and the higher administrative and salary costs at the studied remote clinic compared with those used in the earlier study.10

Strong primary care systems result in better health outcomes and significant cost savings.9,11–13 There is a strong argument for adequate funding of primary care services like the subject of our study. Our findings also highlight the lack of benchmarks that might indicate appropriate levels of funding to meet community needs and provide cost-effective care.

The strength of this study is its rigour and comprehensiveness, using multiple data sources (qualitative and quantitative). However, the methods are resource intensive and replication at other locations or with other disease groups would be expensive. Other limitations include the fact that costs were kept constant in our modelling. It is likely that unit and, possibly, fixed costs will increase as 100% community coverage and adherence to protocols is approached. It may be that 100% coverage and compliance is uneconomical.

Limitations to generalising these findings to other remote Indigenous health centres are the wide variation in transport costs, the availability of allied health care, and the feasibility of indicated insulin treatment given limited staffing resources. The small sample size also means that caution must be taken in generalising the results.

Nevertheless, this community is not unrepresentative of many remote Indigenous communities, and our study provides the best available evidence about the funding gaps for optimal management of two prevalent chronic diseases in such communities. It documents a significant shortfall even in a relatively well funded and effective primary care service, close to the regional centre. We would expect that the documented shortfall is a conservative estimate. These findings should inform funding bodies in their allocation of health resources for remote Indigenous communities. It may also be of use to this and other remote communities in advocating for their health care needs.

1 Estimated 2009–10 and projected annual costs* for the primary care management of type 2 diabetes and chronic kidney disease in a remote Aboriginal community

	Annual costs ($)
Category	2009–10	Projected

Remote health centre costs
Clinical staff	228 906	340 392
Remote area nurses and Aboriginal health workers	62 011	68 592
General practitioners	38 799	74 439
Chronic disease educators and visiting dietitians	128 096	197 362
Administrative staff	76 383	108 507
Medical supplies	4079	5795
Other operating costs	137 217	190 618
Maintenance	1240	1762
Vehicles	27 758	35 123
Other supplies	1635	2322
Other administrative (including computers, power)	106 584	151 411
Total	446 585	645 313
Direct costs to federal and NT governments†	234 424	255 479
Grand total	681 008	900 792

NT = Northern Territory. * Full coverage and full adherence to protocol. † Includes dental (NT), and optometry, non-vehicle and vehicle capital costs, and medications provided to Indigenous patients under s 100 of the National Health Act 1953 (federal).

2 Total projected annual costs per patient* for the primary care management of type 2 diabetes and chronic kidney disease (CKD) in a remote Aboriginal community, by stage of disease and comorbidity

	Cost, by severity of CKD ($)
Condition and case type	No CKD or stage 1–3	Stage 4	Stage 5†

CKD without diabetes
New cases	4345	4547	5200
Existing cases
Without high cardiovascular risk	4062	4175	5042
With high cardiovascular risk	4125	–	–
Non-insulin-treated diabetes
New cases	4428	4601	5252
Existing cases
Without high cardiovascular risk	4133	4228	5093
With high cardiovascular risk	4196	–	–
Insulin-treated diabetes
New cases	14 417	14 590	15 241
Existing cases
Without high cardiovascular risk	14 122	14 218	15 083
With high cardiovascular risk	14 185	–	–

* Full coverage and full adherence to protocol. † Dialysis costs excluded.

A land half won: pain and the modern world

Pain medicine needs to be clear about what can and cannot be achieved

Much has been done by the International Association for the Study of Pain, its members and its national chapters over the past two decades to improve the recognition and treatment of chronic pain. The World Health Organization has similarly mounted a sustained international campaign for cancer pain relief, and palliative care has improved and grown almost everywhere. However, despite real progress, especially in awareness, big challenges remain.

Research has revealed some of the multiple mechanisms at play in causing pain, and multimodal therapeutics tend to reflect this complex neurobiology.1 There is strong emphasis on neuroplasticity, particularly central sensitisation, with the growing realisation that central changes generate pain long after peripheral nociceptive stimuli have waned or disappeared altogether (hence the name change from “chronic” to “persistent” pain). A holistic approach to care — the so-called biopsychosocial model — has been widely and enthusiastically adopted for all forms of pain management.2

Modern pain specialists tend to be polarised into centralists and peripheralists: those who concentrate their efforts on the brain and central nervous system, and those who try to block and modify peripheral structures and processes. Both approaches have validity. To some degree, all pathophysiology can be seen as altered survival mechanisms and almost always involves inflammation.3 It appears that, in the modern world where lives are long and psychological stresses abound, primitive mechanisms to protect us in acute injury play havoc with our ageing bodies and nervous systems. Better blockade of inflammatory pathways must still be a Holy Grail of medical research.

For many years, pain and palliative care specialists saw their main challenge as “opiophobia” — how to overcome community and professional reluctance to use opioids for pain. Opioids have fairly clear roles in both severe acute pain management and palliative care. However, longer-term opioid monotherapy is discouraged in most patient populations, in favour of multimodal strategies, and indications for the use of opioids have been tightened because of widespread misuse, dependence and diversion.4

In a world that expects quick fixes for everything, and where medicine has promised much, expectations and capacity for medical amelioration of pain often far exceed reality, to say nothing of the economic realities of increasing access to specialist services.5–7 Pain clinics can only see a small fraction of patients who have pain; medication and procedures often do not cure the pain; and increasingly disgruntled patients shop around, often favouring medication over other harder but ultimately more rewarding strategies. Even palliative care faces real challenges in meeting increased demand in a setting of chronic diseases and an ageing population, where dying can take years and pain requires management over months, not weeks.

For the legions of patients with persistent pain that does not respond to multiple drugs and procedures, a more realistic and holistic non-medical approach is needed. Many pain services have remodelled what they do on the pioneering work of the Hunter and Fremantle services.8,9 Patients are encouraged to wean themselves off drugs, especially opioids, and to recognise that yet another operation or procedure is unlikely to help where others have failed. Physiotherapists and psychologists work with patients’ natural defensive mechanisms that lead to fear of movement and activity, and help to engender healthy pacing of activity and rebuild confidence that life is possible without pain being a barrier to everything.9

It is widely acknowledged that psychological factors have a big part to play in the genesis and maintenance of persistent pain.10 Patients with long histories of refractory pain need to know and understand that the pain has rewired their brains, with factors such as failure of early nurture, trauma, accidents, drugs and alcohol, and social and economic disadvantage all potentially contributing to dependence, depression, an external locus of control, and anger. There would appear to be considerable scope for more psychodynamic work in pain management.

Community participation projects involving art, music, gardening and physical therapies can achieve surprising results for patients with persistent pain. One good example of such an innovative approach is the Blackthorn Trust, an independent service with a National Health Service contract in the United Kingdom.11 Its work is based on the principles of anthroposophical medicine, developed from the original insights of Rudolf Steiner (1861–1925). Patients start with a conventional medical consultation, build up trust and restore lost energy with physical therapies such as eurhythmy and rhythmic massage, and become involved in a gardening community. This process allows rediscovery of the lost or impaired will and encourages a deeper understanding of mind, body and spirit.

Hospices have led the world in blending good medicine with care for the whole person in an environment that models the world and the home. Those who are damaged and suffering from chronic, non-fatal but often medically enigmatic and incurable symptoms, such as pain, substance misuse and chronic mood disorders, similarly need a nurturing but empowering model of care when medical solutions are no longer apparent. Just as palliative care tackles the reality of death head-on, so too pain medicine, and appropriately resourced primary care,12 needs to be clearer about what can and cannot be achieved. Maybe we need more Blackthorns: community innovations that “hold” the person and the pain, in the sense of the term adopted by the late psychoanalyst Donald Winnicott — the aim is “good enough” pain relief, or the best we can do to help people to live as fully as possible when pain cannot be “cured”.13

A functional dependence? A social history of the medical use of morphine in Australia

The history of morphine use in Australia has shaped public perception and current challenges

Morphine has had an important role in the history of Australia and continues to play a major part in the medical, social and economic aspects of this country.1 The extent of its multitude of uses (and misuses), its constant depiction in the media, and its role in the history of Australia have created a complex public understanding of the drug. There is a broad array of perceptions regarding addiction, tolerance, fear of side effects and an association with death, which may complicate morphine’s use in clinical care.2 An understanding of the history of morphine in Australia can enable a greater understanding of its current use, and provide some background to the increases in opioid prescription seen in the past two decades.3,4

Such a rapid expansion in the use of medical morphine has been experienced before in Australia, on a much greater scale, towards the end of the 19th century before the creation of a regulatory system.5 Although Australia currently has the fifth highest per capita consumption of licit morphine, this is a marked decrease from the first half of the 20th century — in 1936, 14% of the world’s legally produced morphine was consumed by Australia, which then had a population of 6.7 million.4,6

Here, we review the history of morphine use and regulation in Australian society, and consider how the past may influence the attitudes and perceptions of the present. We searched the following electronic databases for studies published in English: MEDLINE (1950 – March 2013), the Cochrane Library, PsycINFO (1806 – March 2013), CINAHL, EMBASE (1980–2013), PubMed and ProQuest. Search terms included morphine, opioids, Australia, narcotics and law. These electronic searches were supplemented by hand searches of key references cited, including historical sources.

Early use of morphine

Opium was widely used and unregulated in colonial Australia, although records of its early use are incomplete. Increased use coincided with the arrival of Chinese immigrants during the gold rush of the 1850s, as this population had high rates of opium use for recreational purposes following British importation of opium to China and the subsequent Opium Wars.5,7,8 It was widely available as a raw product, often used for smoking or dissolved in alcohol as a mixture known as laudanum.

Morphine was originally isolated from opium in 1804 by German pharmacist Friedrich Sertürner, but it was initially difficult and expensive to manufacture.9 Laudanum, by contrast, was readily available, cheaper, well known to doctors and patients alike, and showed similar clinical benefits, although it varied greatly in strength and additives. It was not until the introduction of the modern hypodermic needle in 1853 that morphine became more readily used by physicians, initially for surgical interventions.9 The American Civil War (1861–1865) saw the first use of morphine on a wider scale, where, especially due to its multiple routes of administration and short onset of action, it was recognised for its utility.

Morphine gained popularity in Australia in the 1860s, marketed as an antidiarrhoeal medicine for infants and young children at a time when infantile diarrhoea was responsible for around a quarter to half of all infant deaths.10 Morphine and laudanum were sold virtually unregulated, often by door-to-door salesmen in the form of mixtures, powders and lozenges. The use of morphine increased as physicians became more accustomed to prescribing, dispensing and administering the drug, and societal recognition increased due to marketing through newsprint and magazines.10 Compared with laudanum, which was often inconsistent in strength, morphine was recognised as having standardised dosing and therefore a predictable effect.

Growing concerns

The wide availability of opioids continued unregulated, with neither the public nor government expressing appetite for change, for two main reasons. First, the morbidity associated with infantile diarrhoea ensured great public support for unrestricted availability of a possible remedy. Second, the Australian population was widely dispersed, and with few experienced medical practitioners there was a need for fast access to these medications.10

However, the harmful effects of opioids became increasingly evident over time. In the 1880s, Queensland coroners investigated 98 infant deaths and determined that 15 of these children had been given “infant soother” drugs, most of which contained opioids.10 Coronial records demonstrate that increasing numbers of infant deaths related to opioids were investigated in the 1890s and early 20th century, and doctors became reluctant to sign death certificates in cases where opioids had been used.10 While anxiety surrounding the overuse of opioids for infants grew, for many, the benefits continued to outweigh possible harms.

Australian society seemed largely indifferent to the use of medical opioids for recreational or habitual use, as this practice remained mostly invisible and of little moral consequence.5 The use of opium for smoking was viewed differently, being closely associated with the Chinese population and carrying particular social and racial stigma.8 The Chinese immigrants at the time were poorly accepted in many respects, due to their foreign customs and language, yet the smoking of opium was a very visible vice to which racist sentiment could easily be attached.5 As The Bulletin wrote in 1886, “… where the legions of aggressive stinks peculiar to Chinamen seem ever to linger … The very air of the alley is impregnated with the heavy odour of the drug”.5

Legislative changes

The first Australian laws to limit the supply of narcotics appeared in 1897 in Queensland, largely as a response to the anti-Chinese sentiment surrounding opium smoking rather than as a harm-reduction measure.5 These original laws prohibited the smoking and supply of raw opium but did not address control of medical opioids. In the following 10 years, the remaining states passed similar laws. In 1913, a Bill was passed in Victoria requiring a medical prescription for the supply of opioids, with other states soon following.11

The trend towards regulation soon turned towards criminalisation. With tighter regulation, profiteering from illegal markets increased, and international opinion supported changes aimed at more stringent control, particularly in the United States. The first international drug control treaty was created in The Hague in 1912, with Australia signing the following year.12 The Hague International Opium Convention originally sought to control the international trade of opium and cocaine, but over time placed further restrictions on trade, manufacture and use of all narcotics and psychotropic drugs. At this time, there was a significant cultural shift around the use of opioid medications in the US, which had previously tolerated a free market for these substances, similar to Australia. By 1922, courts had interpreted the Harrison Narcotics Tax Act, passed by the US Congress in 1914, as meaning it was illegal to supply narcotics for people with opioid addiction. Around 25 000 physicians were charged under this legislation in the US, with 3000 serving prison sentences.11

These international influences significantly shaped Australia’s policy on opioids. In 1927, New South Wales passed a Bill providing criminal sanctions against recreational narcotic use and supply. Despite such measures, use continued to grow, with increasing consumption of morphine and heroin nationally.6

A series of legislative acts in the US in the 1950s increased the severity of criminal sanctions for narcotic use and supply, ensuring prescribing of opioids only occurred in narrow, clearly justified circumstances.13 This influence stretched to Australia, with public opinion favouring a criminal justice approach to the problem, leading to increasing numbers of arrests for opioid misuse and supply from 1960 to 1990.11

Conclusion

The history of morphine reflects its effects — of being able to provide great relief or cause significant harm. Despite remaining unchanged as a medication since its discovery, its uses and perception have changed considerably and have been profoundly affected by the legal and political climate in a manner unlike few, if any, other medications in Australia. The place of morphine in our society has been transformed from one of widely unregulated acceptability to decades of intense scrutiny governed by a legal and regulatory framework and increasing levels of public concern. Its uses extend beyond the scope of the medical sphere, as a device of recreation and habit, and also as an important source of legal export income — opioid production is worth about $100 million annually to the Australian economy.1

What the future holds for morphine is uncertain. The history of its use demonstrates the harms of poor regulation and, with a rising tide of deaths attributable to opioids in Australia and internationally, this appears to again be an increasing problem.3 Yet to strictly control these medications, as was done in the mid 20th century, is not without its costs. Society has been adversely affected by the decision to persecute doctors and to not allow supervised access to these medications for patients with genuine pain. Government and media condemnation of opioid use has had a detrimental impact on the public perception of opioids, especially in oncology and treatment of terminal disease, where they may be needed most.2

The impact of the history of use, legal and political attention and media scrutiny appears to have had a significant effect on society’s understanding of morphine. An understanding of the past may provide greater insight into the full effect of this evolving social history, enrich our clinical discussions and provide a discourse to guide future use.

Protons

(a friend, his son)

“They said I should beam protons

into his brain

fuzzy with morphine

and pain

in the room where

he hung on shadows

of life, side by side

with death

waiting for me

that I might see his smile

a last time.

Where have you gone beams

of particles or light or waves

that my son

could not ride you

back to this world.

They said I should not live in anger.

They don’t know

I don’t know why

I’m not packing my bags

to carry him across

the valley of sadness.

They don’t know

anger lives in me, raging fire —

the colour of

consumed life.”