Australia legalised medicinal cannabis in February 2016, but as of May this year, fewer than 150 people had been given legal access. With the growing body of scientific evidence, will medicinal cannabis be able to save us from the increasing pressures on our health system caused by chronic pain and an ageing population?
Chronic pain costs Australia billions of dollars a year
In 2013, epidemiological research published by Henderson et al in the journal Pain Medicine estimated 15.7% of Australians were living with chronic pain. That’s around 3.8 million people based on 2016 population figures.
Previous research by the MBF Foundation estimated the societal costs of chronic pain in Australia at $10,847 per affected person in 2007, mostly due to premature death and disability, health system and productivity costs.
If we assume a prevalence rate of 15.7%, update the per-person costs to 2016 dollars ($13,453.12) and take the national December 2016 population figures (24.3 million), chronic pain currently costs Australia over $50 billion a year.
And it’s getting worse
We are all aware of Australia’s ageing population. And chronic pain is much more prevalent among people 45 years or older. A comprehensive forecast has not been attempted here, but to illustrate, this is the age distribution of chronic pain prevalence in Australia:
And this is a forecast of the proportion of Australians who will be 45 years or older from 2016 to 2050:
Chronic pain is affecting more Australians, causing more suffering, and costing more money than ever before. And it’s getting worse.
Chronic pain has many causes
The biological, psychological and environmental aspects of chronic pain – and their interaction and reinforcement – can make it very hard to treat.
It’s something many people have experience with, either personally or through a loved one: the feeling of persistent pain is unpleasant, and you learn to avoid physical activities that make it worse. You become more sedentary, leading to additional problems and new sources of pain. This impacts your sleep and make you anxious, so your work suffers. You become irritable and frustrated, and take more medication to cope. The spiral continues.
And can be hard to treat
Around 80% of Australians reported osteoarthritis or back problems as the cause of their chronic pain, which are both more difficult to treat if the person is overweight. Unfortunately, a majority of Australians in the most at-risk age groups for chronic pain, osteoarthritis and back problems are either overweight or obese.
This trend is not unique to Australia. A combination of longer lives, higher rates of obesity and sedentary lifestyles has contributed to neck and lower back pain becoming the leading causes of disability in every high-income country in the world.
Pharmaceuticals can help
Although multidisciplinary pain management can help address the psychological, environmental and physical causes of chronic pain, around 85% of Australians with chronic pain use pharmaceuticals, and over 55% rely exclusively on pharmaceuticals to manage their condition.
The most common pharmaceutical is paracetamol, used by 42.8% of Australians with chronic pain, although there is very limited evidence that this is an effective treatment for chronic back pain, and its effectiveness in treating acute back pain has recently been thrown into doubt. The second most common class of pharmaceuticals are opioids, used by 34% of Australians with chronic pain.
But they have their own risks
The level of opioid use is a major public health concern, as these medications can have very unpleasant side effects including nausea, vomiting, constipation and dizziness. Not to mention the additional harms people are exposed to through misuse and abuse of prescription opioids. But a lack of viable alternatives, and the persistence of chronic and other types of pain, has helped accelerate opioid use in developed countries.
In the USA, levels of prescription opioid use and abuse have reached epidemic levels. In 2014, nearly 2 million Americans were addicted to or dependent on prescription opioids, and nearly half of all US opioid overdose deaths in 2015 involved a prescription opioid. That’s more than 15,000 people.
Similar trends have been observed in Australia: from 2001 to 2013, the number of Australians using prescription opioids increased by 300%. And from 2003 to 2013, the prescription rate of the opioid Oxycodone increased by 600%, alongside increases in deaths and hospitalisations from prescription opioid overdoses.
We know cannabis is a viable alternative
According to the Health and Medicines Division of the U.S. National Academies of Sciences, Engineering, and Medicine, ‘there is substantial evidence that cannabis is an effective treatment for chronic pain in adults’. Compared with paracetamol, there is significant evidence that cannabis is an effective treatment for many types chronic pain including lower back pain and osteoarthritis. Compared with opioids, cannabis offers a highly effective treatment option with a risk profile lower than codeine.
Medicinal cannabis, when used in conjunction with other medicines, and with appropriate multidisciplinary pain management strategies, can substantially reduce opiate use. Although rigorous clinical guidelines are still being developed in this area, there is compelling evidence that access to medicinal cannabis is correlated with significant reductions in opiate prescriptions and overdoses. This is supported by macro-level data as well as patient survey studies.
So, when will Australian doctors start prescribing cannabis for chronic pain?
Some already have, but it can be hard for doctors to educate themselves on the emerging medical scientific evidence while also navigating new and quite convoluted approval processes. From what we’ve heard so far from patients, carers, the Office of Drug Control and the Therapeutic Goods Administration, the main challenges include:
- Unclear State and Territory approval processes
- A lack of clinical guidelines for physicians
- High prices of available cannabis medicines
- A lack of education available for physicians, scientists, regulators and entrepreneurs
But some, albeit slow, progress is being made. The Federal Department of Health currently is developing clinical guidance documents for epilepsy and chemotherapy-induced nausea and vomiting. Hopefully chronic pain will be next on their agenda. And there are some positive patient access reforms that have been made in South Australia that other States could certainly learn from.
As domestic manufacturing comes online throughout 2018, cheaper local medicines should become available, and developing medicines for chronic pain is a primary focus for many cannabis companies. And there are several groups – including Cann10 Australia – working on developing and delivering education and training programs.
In the meantime, it is up to all of us involved with medicinal cannabis to continue lobbying and working towards practical solutions to these challenges.
You can learn more about the political, economic and medical aspects of cannabis by enrolling in the Cann10 Medicinal Cannabis Leadership Program.
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 Henderson, J., Harrison, C., Britt, H., Bayram, C. and Miller, G. (2013). Prevalence, Causes, Severity, Impact, and Management of Chronic Pain in Australian General Practice Patients. Pain Medicine, 14(9): 1346-1361
 Access Economics Pty Limited (2007). The high price of pain: the economic impact of persistent pain in Australia. MBF Foundation: 52
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