Persistent pain

A collaborative approach for ACCHOs

This resource supports GPs and other clinicians working in Aboriginal Community Controlled Health Organisations (ACCHOs) to deliver collaborative, culturally responsive care for clients with persistent pain, with a strong focus on non-pharmacological treatments and multidisciplinary.

Understanding persistent pain

Persistent pain is defined as pain that continues beyond the expected healing period following injury or illness—typically lasting more than three months—and may occur even in the absence of ongoing tissue damage.¹ As time passes the severity of the pain becomes unrelated to physical indicators of injury or illness.

The pain is real, complex and deeply personal. It can isolate people and seep into their identity.

Persistent Pain impacts relationships, the ability to work, participate in daily activities, and maintain overall quality of life.² Pain is understood to be shaped by a combination of biological, psychological, and social influences that affect the way the brain interprets sensations.

The beliefs and approaches of health professionals affect the way clients see their own pain and impacts recovery. By having realistic, supportive and hopeful approaches to pain management many clients can recover. The biopsychosocial approach to persistent pain management recognises that pain is influenced by a dynamic interplay of factors and calls for a holistic, person-centred approach to treatment.¹ Cultural safety and trust lies at the centre of this approach and requires an understanding of the ongoing impacts of racism and colonisation.

ACCHOs are uniquely positioned to lead in this area. Their culturally safe, holistic model of care integrates traditional healing practices, active listening and trust-building and multidisciplinary, non-pharmacological treatments.

This approach supports comprehensive, culturally responsive pain management tailored to the needs of Aboriginal and Torres Strait Islander peoples.

Take home messages

Effective pain care in Aboriginal and Torres Strait Islander communities starts with building trust, using culturally respectful communication, and creating safe spaces for clients to share their stories.
Focus on function and quality of life instead of pain relief.
Collaborate and build a holistic team around the client – led through the ACCHOs and including Aboriginal and Torres Strait Islander Health Workers and Health Practitioners to support the clients goals.
Reducing reliance on medicines and prioritising non-pharmacological, culturally grounded treatments is essential.
Continuous reflection, collaboration, and integration of cultural knowledge strengthen care and empower clients to manage pain in ways that align with their values.

Supporting clients with persistent pain

Persistent pain is a complex and deeply personal experience—one that is often underreported and undertreated in Aboriginal and Torres Strait Islander communities.⁴ Within our communities lies a profound strength: a deep connection to culture, family, and community. In many cases, cultural and community responsibilities may take precedence over individual health concerns. For health professionals, recognising and respecting these values is not only essential—it is foundational to delivering care that is truly effective and culturally safe.

The ongoing impact of racism and discrimination shapes both the experience and expression of pain from clients and the behaviours of health professionals. It must be acknowledged. It erodes trust in the healthcare system and discourage individuals from seeking help. Building trust begins with listening, learning, and creating space for culturally grounded conversations about pain.

Addressing barriers and building trust

Understanding the unique challenges Aboriginal and Torres Strait Islander peoples face in pain management is essential for delivering culturally safe and effective care.⁵

1. Cultural variability in pain expression

Pain is universal, but its expression and interpretation are culturally influenced.
Aboriginal and Torres Strait Islander clients may express pain differently to how medical professionals understand pain or have been trained to examine pain, leading to under-recognition or misinterpretationby clinicians.

2. Communication barriers

Clients experiencing persistent pain often report negative experiences such as judgement, stigma, not feeling heard or being disrespected.
Miscommunication can result in inappropriate treatmentand harm caused by the care itself.
This leads to fear and denial with both the clients and the clinicians in relation to pain treatment.

Intentional actions are required to ensure clinical settings have culturally appropriate communication strategies targeting barriers.

3. Access challenges

Previous negative experiences and encounters with culturally unsafe or dismissive care impacts how both clients and healthcare professionals engage with persistent pain.

Geographical isolation, service design and local realitiesmay limit availability of services.
High costs, perceived or real, related to treatment options, travel, and time away from work and family contribute to financial barriers to accessing care.
Workforce challenges impact clinicians’ sense of personal and professional safety, limiting capacity to safely engage with clients.

4. Practitioner beliefs and bias

Some clinicians hold unfounded beliefs(e.g. that Aboriginal and Torres Strait Islander people are more stoic than others or, holistic services are not available or effective for pain management).

These beliefs are not evidence-based and contribute to undertreatment and dismissal of pain that is reducing function and quality of life.

5. Cultural safety of assessment tools

Common pain assessment tools may lack cultural relevanceor cause discomfort.

Using inappropriate tools can unintentionally shift power away from the patient and into the hands of the practitioner, undermining patient empowerment.

6. Systemic and research gaps

High-quality, culturally informed researchon pain in Aboriginal populations relatively limited in volume and scope.

Pain studies often lack community consultation and exclude grey literature and community knowledge, limiting insights and relevance to Aboriginal and Torres Strait Islander People.

Creating safe spaces to yarn about pain

Establishing a culturally safe environment is essential for supporting Aboriginal and Torres Strait Islander clients living with persistent pain. A safe space fosters trust, encourages open dialogue, and supports healing. When clients feel heard, respected, and understood, they are more likely to engage in care and share their pain experiences honestly.

Key principles for culturally safe pain conversations

1. Build trust through cultural safety

Engage in ongoing cultural safety training, especially for non-Indigenous staff.
Understand the historical and ongoing impacts of racism and colonisationon health and trust in healthcare systems.
Understand the history of pain treatments and impacts of this on clients today.
Involve community voicesin service design and delivery to ensure care is relevant and respectful.

2. Communicate with respect and clarity

Use plain languageand avoid medical jargon.
Prioritise active listening—show genuine interest and empathy.⁶
Apply culturally appropriate communication strategies, such as:
- Clinical yarning
- Finding your wayshared decision-making model
Use interpreters, cultural liaison officersor Aboriginal and Torres Strait Islander Health Workers and Health Practitioners when needed.
Validate the client’s pain story—listening and believing is therapeutic.

3. Reflective practice for continuous growth

Reflect on personal beliefs and unconscious biasesthat may influence clinical decisions.
Reflect on your education in relation to pain and its treatment.
Consider how your own worldview may shape your interpretation of pain and behaviour.
Create space for self-reflection and peer discussionto improve cultural responsiveness.

4. Use culturally relevant tools and approaches

Where available, use culturally validated pain assessment tools.
Recognise that pain is multifaceted – shaped by physical, emotional, spiritual, and cultural factors.
Respect that cultural engagement and expression varies – some clients may draw on traditional practices, others may not.

5. Collaborate with community and colleagues

Involve Aboriginal and Torres Strait Islander Health Workers and Health Practitioners and community membersin care planning.
Support holistic approachesto pain management, including traditional healing practices where appropriate.
Foster a team-based approachthat values Aboriginal and Torres Strait Islander knowledge and lived experience.

Creating a safe space to yarn about pain isn’t just about what you say—it’s about how you listen, how you show up, and how you honour the client’s story.

Focus on recovery and improving function

The way we understand and talk about persistent pain is evolving. Rather than focusing solely on pain scores, we now prioritise improving function and quality of life—supporting clients to do more of what they value.⁷

Equip clients and teams with culturally relevant, strengths-based

Our Mob | Pain Management Network – factsheets and resources
Yarning about managing pain – (YouTube video)
Staying Strong with Arthritis – (website)
NACCHO – Chronic pain (online course)

Support clients to define and track functional goals in their own words—specific, meaningful activities that reflect their daily lives, values, and aspirations.⁸

ACI Pain Management Network has a range of assessment tools and resources to enable development of a Pain Management Plan.

Consider building locally adapted templates and plans from the mainstream tools below noting these have not been developed with Aboriginal and Torres Strait Islander people:

Patient Specific Functional Scale – to track progress on chosen activities
Pain Disability Index (PDI) – to understand how pain affects life roles

Encourage goals that focus on:

Movement and activity

Promote physical activity as a key to recovery

Self-management

Co-create realistic, empowering plans

Reduced reliance on medications

Explore safe, culturally appropriate alternatives

Safe and informed use of Opioids

Long-term opioid use is no longer recommended for persistent non-cancer pain due to increased risks,^9,10. Aboriginal and Torres Strait Islander peoples experience higher rates of opioid-related harm.¹¹and are 3–4 times more likely to die from opioid overdose—often from prescribed medicines.¹¹ Inappropriate prescribing can unintentionally cause harm, reinforcing the need for informed, culturally safe decision-making.¹²

Many clients have been on opioids prescribed by trusted clinicians for many years. For more information and guidance on the safe deprescribing of opioids please see:
MAIA Persistent Pain topic NPS Opioid Tapering Advice.

Talk about opioid safety and provide naloxone to clients at risk or respiratory depression. If you are not a naloxone provider then talk to the client or family and find them a way to access this life saving drug.

ACCHOs are uniquely positioned to deliver safe, effective, and culturally grounded persistent pain that reduces the reliance on pharmacological treatments.

Provide holistic, multidisciplinary support

A multidisciplinary approach is widely recognised as the most effective strategy for managing persistent pain.¹³

Clinical team members may include:¹⁴

General Practitioners (GPs): Coordinate care, monitor progress, and facilitate referrals.
Aboriginal and Torres Strait Islander Health Workers and Health Practitioners: Provide culturally safe communication, advocacy, and integration of traditional healing practices.
Psychologists: Support mental health, coping strategies, and behaviour change.¹³
Occupational Therapists: Promote safe movement, daily function, and confidence in activity.¹⁵
Social Workers / SEWB Teams: Strengthen community connections and address social determinants of health.
Physiotherapists / Exercise Physiologists: Deliver tailored exercise programs that support functional improvement.
Pharmacists: Optimise medication safety, provide education, and support deprescribing where appropriate.

Non-clinical team members also play a vital role. They may include:¹⁶

Clinic coordinators: Ensure smooth care coordination and follow-up.
Administrative support staff: Assist with scheduling, communication, and continuity of care.
Peer support workers: Offer lived experience, emotional support, and encouragement.
Community engagement officers: Foster trust, promote services, and strengthen links between the health service and community.

A collaborative, team-based approach helps address the isolating nature of persistent pain and ensures care is comprehensive and coordinated. To strengthen this model within your ACCHO:

Use case conferencingto bring together team members and ensure shared understanding of client needs and goals.
Keep clear and up to date records including GPMP and 715s for easy referrals to allied health as needed.
Develop partnershipswith local healthcare providers to improve access to non-pharmacological treatments such as physiotherapy, psychology, and occupational therapy.
Increase allied health involvement to support a broader range of treatment options.

Integrating culture and community

Where possible, establish and expand dedicated pain clinics within the ACCHO to provide holistic and multidisciplinary care.

Incorporate local and appropriate traditional healing practices—such as ceremony, native foods, spiritual medicine, and Country as medicine—into care plans, in consultation with Aboriginal and Torres Strait Islander Health Workers and Health Practitioners.^10,17
Establish pain support groups and strengthen SEWB teams to provide peer connection and holistic support.
Recognise and respect differences in cultural engagement and expression, ensuring care is flexible and responsive to each client’s values and preferences.

I had bad pain in my back and legs for more than 6 years and was feeling really sorry for myself - I was thinking 'How will I be able to live with this?'. My doctor referred me to an exercise physiologist and then to persistent pain classes - at the start I could hardly lift my feet, but after a couple of months I could almost run! The classes helped me understand more about pain and about my body and taught me how my mind can work even better than medicines to help with the pain. Even now, when the pain triggers, I use those skills from the pain clinic!

– Aunty Patricia

(Gympie)

Persistent Pain Service – A Caring Pathway for Mob

Yarning About Pain – program

Who
Moreton ATSICHS – Institute for Urban Indigenous Health (IUIH)

Clinic setup
Started in response to community requests.
Monthly visits by pain specialist, physiotherapist, psychologist and pharmacist.
Monthly multidisciplinary team (MDT) meeting to discuss client management.

Referral process
GPs provide referrals to the pain specialist. A dedicated staff member coordinates patient appointments through the clinic. Patients must engage with the physiotherapist and/or psychologist to continue seeing the pain specialist.

The team

Pain specialist Pharmacist
Physiotherapist GPs
Psychologist Clinic coordinator

Funded by Rural Doctors Workforce Agency (RDWA) in South Australia

Who
Sunshine Coast Health Persistent Pain team, Health Services and community engagement

Clinic setup
Monthly sessions held at a local, culturally safe community hub.
Information sessions conducted twice monthly to engage new community members.

Referral process
Clients are referred to the clinic from GP services, including Aboriginal Medical Services (AMS).