Editor’s note: The 17th IASP World Congress on Pain took place September 12-16, 2018, in Boston, US. At the Congress, 12 early-career pain researchers took part in the PRF Correspondents program, a science communications training experience that provides participants with knowledge and skills needed to communicate science effectively to a wide range of pain researchers and to patients and the wider public. As part of this program, the Correspondents conducted interviews with plenary speakers.
Here, plenary speaker Fiona Blyth, PhD, sat down to chat with PRF Correspondent Valerie Hruschak, a PhD candidate at the University of Pittsburgh, US. Blyth is a professor of public health and pain medicine at the University of Sydney, where she is head of the University’s Concord Clinical School at Repatriation General Concord Hospital and is in the leadership group of the Faculty of Medicine and Health. Blyth also is head of intramural research at the Sax Institute, a national and international leader in research on healthy aging and health services research, and a senior adviser in the Institute’s Knowledge Exchange Division, where she is involved in bridging the gap between policymakers and researchers. Blyth’s research focuses on the epidemiology of chronic disease, with a specific interest in pain-related conditions. This includes large prospective cohort studies, randomized controlled trials, pharmaco-epidemiological studies, and health services research. She has been named a Member of the Order of Australia for her significant contributions to medical research and education, public health, pain management and aging, and health policy reform. The Order of Australia, established in 1975 by Elizabeth II, Queen of Australia, recognizes individuals for achievement or meritorious service.
In this interview, Blyth discusses her path to pain research, why it’s important to take a population-level approach to understanding chronic pain, the pain research landscape in Australia, and much more. Below is an edited transcript of the conversation.
What led you to pursue a career in pain research?
My background is in public health and medicine, and I was aware of the emerging idea of chronic pain as an entity. I thought that if I was going to do a PhD, I would like to do it in an area where there is not a lot of information because it might be more useful to describe the impact of something that has not already been well characterized. That was my motivation, and because I could see that pain was a complex phenomenon, I found it intriguing.
Before I did my PhD, I trained in medicine and worked in hospitals for several years, and had done a lot of my general practice training. I was involved in quite a serious car accident, and for a long time I could not work clinically. To avoid going crazy, I pursued a master of public health degree and became a public health physician, which was my trajectory into being a population scientist.
Did you experience pain from your car accident?
Certainly—I had many orthopedic injuries. It took a bit of time, but I was lucky that I received good treatment and made a strong recovery. I can draw on those experiences of how I was managed at a system level. This issue remains a problem for people who are injured at work. The way the system responds today does not seem to align with what we understand is the best way to respond to injured people, and I most definitely experienced that.
Recently you were awarded a grant to investigate how to reduce the risk of developing chronic pain. Can you explain this work and its importance?
Given the size of the problem of pain, it is clear that the solution at a population level lies with people with pain themselves but also with community and primary care providers. Understanding the extent to which other resources and skills are necessary, and the degree to which they exist in primary care, is a really important question. In Australia, there was an emphasis on this because of government changes to codeine availability. In February of last year, all codeine formulations became prescription-only and prior to that, low-dose codeine and paracetamol combinations were available over the counter. There was a lot of concern in the community in the lead-up to this new regulation and the question was, If I can’t take these medications, what else am I going to do?
This has prompted the broad question, What should be available in primary care settings for people with chronic pain? The project I am leading is examining what is happening in primary care spaces around Australia, and to what extent that aligns with what we might understand is the best model of care for managing not only chronic and disabling pain, but the stages before that. For example, how are people being identified as being at risk for developing chronic pain? What is the system response at a local level? And what are the needs and barriers to primary care practitioners implementing that model of care?
Australia is an enormous country geographically, with a population concentrated around cities but also scattered across inland areas, and we have a very large immigrant population. Particular populations such as our Aboriginal communities have a range of challenges in terms of health, and we do not understand the best way to deliver pain services. Having started this project, we are starting to realize how very different these primary health networks are. It has motivated us to obtain extra funding to examine the different types and models of the networks themselves before we try to understand how they are dealing with pain. This is because, at the end of this project, we want to give primary health networks some tools to conduct needs assessments. We also hope to find some evaluation of existing programs in the networks, so we can say what is achievable to those networks that have not yet funded programs.
With regard to pain, is there previous work in Australia looking at the diversity of the population you describe, and if so, how are you using that to inform your work?
This is not limited to Australia, but a lot of the research about what is broadly called ethnicity and pain is fairly blunt. When we think about people coming from a different culture and their experience of pain, some of it may be because of their cultural beliefs but also because of other life circumstances—things like their level of education, overall socioeconomic and social living circumstances, and occupational exposures all play a role and sometimes those aspects are not unpacked sufficiently.
One of my junior colleagues and former students looked at the health of Italian- versus Australian-born men, and they did find a difference in back pain. However, when you actually unpacked the difference, a lot of it was driven by their socioeconomic circumstances. In order to understand diverse populations, it is important to look at multiple dimensions. Some of the differences in the experience of pain will be due to cultural beliefs, but a lot is the result of other things about one’s life circumstances.
What are some of the more challenging, frustrating, or stressful parts of the work that you do?
As is universally the case, getting funding for projects is always an ongoing issue. It is a problem because we work in a relatively small professional group in our national setting.
There is a very strong signal in population studies about the size of the problem of pain, but having that signal understood and acted upon at a policy level also remains a challenge. Recently I started collaborating with policy scientists, because if we want to have systemic change, it has to involve policies that deal with the problem. Probably 20 years ago, I would never have thought I would work with a group like that.
Sometimes we can get stuck in our own silos, so stepping back and seeing things from different perspectives sounds like it’s been helpful in your own work.
Yes, but everyone is different. Some people prefer to have a career of enormous depth within a particular area, and do a fantastic job. But for me, it always was obvious, from the very early stages, that my career would be more a question of making broad connections across different groups. Seeing that the problem of pain was common to so many areas of health and life, I knew intuitively, early on, that I would need to take a broad approach.
What do you view as your most significant accomplishments?
In terms of work that has had the most impact, surprisingly, it was the first research that I published out of my PhD, which was a study about the prevalence of chronic pain in my home state. It was the first time our state conducted any survey on the health of adults in New South Wales, and I managed to get two questions on pain into that survey. When the results came back, everyone was surprised at how common chronic pain was. The beauty was that it was the health department’s own survey and data, so they could not dispute or disown it. A number of colleagues around New South Wales said they could use the data from that survey to help support funding for pain services, which was a really concrete outcome.
Also completely unexpected was that I have had feedback from a number of people living with pain who said it was through my work that they had become aware of how common chronic pain is. Many of them commented that before that, they felt very alone, isolated, and a fair amount of stigma because people never talked about their chronic pain. Many felt it wasn’t a legitimate problem to have.
Over the years, a number of people living with pain have said to me that it was important for them to understand that there are a lot of people “like me” in the community and that chronic pain is something that people who work in the health field are talking about. The issue of invisibility and stigma in Australia is a significant one. There has been a huge hunger for information, as there were no patient advocacy groups for people with chronic pain. People felt that they had a problem that was invisible, and they did not know where to go.
When we had our national pain summit in 2010, reducing the stigma of chronic pain was one of the identified goals of the first pain management strategy. I was able to contribute in some way to that particular aspect, which was really rewarding.
Where do you see the field of epidemiology going in the next 10 years?
In terms of public health, the idea that we need to think about pain as a population-level problem is well accepted in the pain field. What we are seeing now is epidemiological techniques being brought into other relevant areas—pharmaco‑epidemiology, for instance. There is a common set of methods and a way of thinking that we can apply. I do not think that any one scientific discipline has the answer for pain, and it’s how we put all of these things together to deal with the problem. Over time people have understood better what epidemiology can offer to the field.
Where do you think that Australia is in the field of pain in comparison to other countries?
Australia has always had a really prominent role in IASP, and is at the forefront of having national policies or strategies around pain. This is because of strong leadership, for example, from Michael Cousins, a pioneer in the pain field in Australia and internationally. So we’ve done really well in that regard.
The issues around funding for research in Australia are difficult, as they are in many countries; that does remain a challenge. But we see ourselves as a regional entity as well, so in relation to our part of the world and South East Asia, where some really interesting initiatives are happening, many of us have been quite involved working collaboratively with our partners in South East Asian countries. That has been a really exciting development in the last five to 10 years, and it has involved exchanges for training and collaborative research projects, and implementing things that we know work in Australia but adapting them to local conditions in countries like Malaysia and the Philippines. I see all of those as really important contributions that Australia and being a part of IASP is making to our region.
Who has influenced you the most in your career?
That’s a really hard one. In terms of how I think about health and populations, the late Geoffrey Rose, who was a British giant of public health, was the person who inspired me in the field of public health. In the pain field, I was lucky when I started my PhD to do it in the context of the very important work that Michael Von Korff, from Seattle, had been doing, both in developing measures that could be used within populations and doing very high-quality epidemiological research.
But I am inspired by so many people in the pain field, even if their areas are not immediately applicable to what I do. I have enormous respect for the work that is being done in the many disciplines that make up the tribe of pain.
What advice do you have for trainees or early investigators in the field?
It is really important to train well to be a good scientist in your field but to do that in the context of something that you really believe in, are passionate about, and will keep following. But it’s also important to remain curious about things happening outside your field. You also have to look after yourself and develop a trustworthy group of mentors and peers that you talk to regularly, and understand that the people you see who are 20 or 30 years down the track have had just as many setbacks and failures as you are worried about at your career stage. Of course, what is visible are their successes, but all of us have had failures and setbacks, but have learned from them and kept going.
Any final thoughts, words of wisdom, or anything else you would like to share?
When I come to meetings, I am always inspired by the energy and enthusiasm of young investigators, and it is wonderful that they bring their own way of thinking into the field. It really is one of the things that I enjoy most about attending the IASP World Congress.