A couple of weeks ago, I had a mock interview for a new research fellowship with our national research council. In my rather sheltered life, these interviews are a rather big deal – whether or not I am to remain a government-funded medical researcher hangs on the line and the chances are intimidatingly thin. The mock interview then, aims to give you a practice run and prepare you for the inevitable – a question you didn’t expect from a panel member who doesn’t think the problem you are investigating is as important as others, or that you have squandered the opportunities given thus far by failing to publish in Science or Nature*, or just doesn’t like the sound of you. The question I got, from an outstanding implementation scientist who does high impact work actually changing how doctors prescribe medicine, was this:
“So, you keep telling us how massive a problem chronic pain is, and chronic back pain in particular – that it tops the leagues tables of health burden. Isn’t that pretty damning evidence that the last 15 years of your research hasn’t achieved anything? Do you think Australia should invest in another 5 years of not achieving anything?”
Tricky question huh? I thought I did OK on the answer – claiming that we have no idea how bad the problem would be if it weren’t for me etc etc…. However, if I got the question now I might just have a different take. A more hopeful and potentially exciting take. At least I would if was from the US.
The USA burden of disease data were published a couple of months ago in JAMA and they are getting a bit of air time. The paper is now freely available and it makes for excellent bedtime reading (if you are preparing an application for research funding….). There is the usual stuff – lifestyle factors are contributing in predictable ways to health, with the top 4 risk factors being tobacco consumption, high BMI, alcohol and drug use. Back pain remains the biggest burden with respect to years lived with disability, followed by depression. Age-standardised rates of major depressive disorder have remained at 1990 levels (bad news for a depression researcher heading for interview….). However, and here is some good news – age-standardised rates of years lived with disability due to back pain have dropped by 12.4% on 1990 levels. In disability-adjusted life years, which accounts for years lost because of premature death PLUS years of productive life lost due to disability, back pain has dropped from 3rd to 5th, and a drop of 12.1% on 1990 levels.
A 12.4% drop in years lived with disability is probably a good thing and if the statistics are as they seem, it is a massive thing. We are talking a reduction in millions of collective years; hundreds of millions of collective days. This might not pack a punch for those of you who don’t have back pain, but for those of you who do – who wake up with back pain, don’t do stuff you want to because of back pain, go to bed with back pain – this packs a mean punch indeed: compared with 1990, there are now hundreds of millions less days like this.
Of course, I would not be so ignorant as to claim in interview that it is my work that has led to that 12.4% drop, but I would point to what seems to me to be a hopeful statistic. The first hopeful statistic – when it comes to pain – that has emerged from burden of disease studies in 20 years. Let’s just dream for a moment – dream that this is the turning point. And hope – hope that it continues this way and that this is not a blip but the first evidence of a worldwide trend. Only time will tell.
There is a sting in the tail however. Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016 – a 74.5% increase and a 48% increase in age-standardised DALYs. There was ‘only’ a 10% increase in years lived with disability due to opioid use disorders, which points to the tragic reality that Americans are dying from opioids. Not new news, but a reminder of bad news.
As a pain researcher, am I likely to have nothing to do anytime soon? Obviously not: back pain (5th on DALYs), opioid use disorders (7th), migraine (10th) and neck pain (11th) still peer down from the top of the league tables onto higher profile health issues such as breast cancer (20th) and OA (25th – although the pain of OA is arguably of major impact here too), and sit among depression (9th), diabetes (4th) and stroke (12th).
But for now I am taking this moment of hope as encouragement for us all to keep on keeping on. By any measure, the acceleration in disability due to persistent pain states has stalled and by one measure at least, it might just be turning back. And that, for millions of Americans, is a good thing. Kudos to all you Americans who have contributed to this – you researchers, clinicians, educators and sufferers.
About Lorimer Moseley
Lorimer is Foundation Chair in Physiotherapy and Professor of Clinical Neurosciences at the University of South Australia, and Senior Principal Research Fellow at Neuroscience Research Australia. He has published 300 scholarly works. His H-index is 59. He leads the Body in Mind Research Group, which investigates the role of the brain and mind in chronic pain. For full bio, go here.
The State of US Health, 1990-2016Burden of Diseases, Injuries, and Risk Factors Among US States. JAMA.
* notwithstanding the common criticisms of these elite journals that they are far more likely to publish findings that no one else can replicate and are ultimately refuted! Grumble grumble – I suspect these criticisms are common among those who have never published there….take me for example….