Dr. Brona Fullen:

I thank the committee for the opportunity to participate in this discussion. I propose to summarise the research that has been undertaken by Dr. Brian McGuire and his team in the centre for pain research at NUIG and by my team and me at the UCD school of public health, physiotherapy and population science. This research has provided the first comprehensive picture of the problem of chronic pain in Ireland and the efficacy of current services for patients.

Chronic pain is defined as pain experienced on a daily basis for three months or more. It can vary in intensity and in the extent to which consequent disability and psychological distress can affect patients. Most people with chronic pain have been suffering for several years before they access specialist services, assuming such services are available in their area. In addition to long waiting lists to access services, multidisciplinary pain management teams - by which I mean teams comprising a chartered physiotherapist, occupational therapist, clinical psychologist, pain nurse and consultant pain specialist - are the exception. People attending pain programmes tend to be significantly impaired by their pain, with both physical dysfunctions and psychological dysfunctions such as anxiety and depression. This makes it more difficult to achieve outcomes that can make a discernible difference to the patient's quality of life.

Research at NUIG has established that the pain prevalence in Ireland is up to 35%. Lower back pain, at 47%, was identified as the most common site of pain in patients, which is line with the international literature. However, more than 80% of patients reported having pain at more than one site.

Some 12% were unable to work or were on reduced work hours owing to pain. Of those with chronic pain, 15% were diagnosed with clinical depression, whereas the number for those without pain was 3%.

NUIG also provided data on the economic cost of pain. Over a one year period and from a sample of 140 patients, the average cost per patient was €5,665. That cost increased as the severity of the pain also increased. This correlates significantly with the length of time for which patients have had pain. A small proportion of patients accounted for the bulk of costs. In other words, there was a mean cost of €30,000 per patient per year among the top 5% most expensive patients. This accounted for 26% of the overall cost among the 140 patients sampled. As Dr. Keaveny stated, NUIG extrapolated from this data and estimated that the total cost to the State in 2008 was €4.7 billion or 2.55% of GDP.

Resources for the management of chronic pain are scarce. In UCD we undertook some research into the need for a national pain strategy, aptly named, and of the 28 pain clinics nationwide, only eight of the 18 which classified themselves as multidisciplinary met the International Association for the Study of Pain criteria for multidisciplinary pain clinics. Similarly, only three out of the ten clinics that classified themselves as pain clinics met the recommended criteria. These clinics also report long waiting times to access services as new patients.

There is evidence that managing patients according to international best practice is effective both in the community and secondary care settings. In UCD we have reviewed the effectiveness of the Ulysses cognitive behavioural pain management programme in Tallaght Hospital over an eight-year period. As Professor O'Connor mentioned, this is one of only two publicly funded, group based, multidisciplinary cognitive behavioural therapy programmes in the State. The second programme is run by St. Vincent's University Hospital. We reviewed 550 patients and discovered that, on average, people had experienced pain for over eight years before they could access the service. They had significantly high levels of functional disability. Some 76% of the patients involved were diagnosed with clinical depression and 85% as being clinically anxious. Six months post the four-week pain management programme there were clinical and statistically significant improvements in the context of both physical and psychological dysfunction. There was also a significant improvement in patients' quality of life. However, with resources, we should be targeting these patients earlier in the progression of their disease. Dr. McGuire and his team at NUIG have identified that targeting people with low back pain for less than one year can, as Dr. Keaveny mentioned, increase return to work levels among and reduce depression and fatigue in such persons. This suggests the type of rehabilitation to which I refer is beneficial in facilitating patients with back pain to return to work.

The findings of research conducted in Ireland demonstrate that pain is both a prevalent and costly health care problem and that chronic pain services are generally and significantly under-resourced. However, there is evidence that improved co-ordination and better management of patients via multidisciplinary rehabilitation programmes, in both the community and health care settings, are effective. The development of a national pain management strategy would enable us to make best use of limited resources, treat patients earlier, reduce long-term disability and associated costs and, most importantly, improve quality of life.