Chronic pain and the use of conventional and alternative therapy

Transcription

1 Family Practice Vol. 20, No. 2 Oxford University Press 2003, all rights reserved. Doi: /fampra/ , available online at Printed in Great Britain Chronic pain and the use of conventional and alternative therapy M Haetzman, AM Elliott a, BH Smith a, P Hannaford a and WA Chambers Haetzman M, Elliott AM, Smith BH, Hannaford P and Chambers WA. Chronic pain and the use of conventional and alternative therapy. Family Practice 2003; 20: Background. Chronic pain is a common problem affecting about half of the general population. This has implications for the utilization of both conventional and alternative health services. Objectives. The aim of this study was to determine the use of conventional and alternative practitioners and medicines amongst individuals with chronic pain in the community. Methods. A total of 2422 individuals from a previous population-based survey in the Grampian region of the UK, who agreed to participate in further research, were sent a postal questionnaire. The questionnaire enquired about the presence, type and severity of chronic pain, sociodemographic details, consultations with conventional and alternative practitioners, and the consumption of conventional and alternative medicines. The main outcome measures were the number and frequency of self-reported consultations with GPs, hospital specialists, physical therapists and alternative therapists, and the consumption of prescription, non-prescription and alternative medicines amongst those with chronic pain. Results. Of the 840 individuals reporting chronic pain, 67.2% had seen their GP, 34.0% a hospital specialist, 25.9% a physical therapist and 18.2% an alternative therapist in the preceding year. Prescription medicines had been taken by 58.4%, non-prescription medicines by 57.4% and alternative medicines by 15.7% of individuals with chronic pain. The majority (67.0%) of individuals with chronic pain who sought alternative health care did so in conjunction with conventional health care. Differences in consultations with practitioners and consumption of medicines were found by age, sex, socio-economic status, site of pain and severity of pain. Conclusions. Individuals with chronic pain consult their GP about their pain more than other practitioners and use conventional medicines more frequently than alternative medicines. Alternative health care is used most commonly in addition to conventional health care, although a small number of individuals with chronic pain use alternative care exclusively. The use of alternative health care amongst those with chronic pain is higher than previously estimated and suggests that the use of these services may be increasing amongst those with chronic pain. Keywords. Alternative health care, alternative medicine, chronic pain, GP. Introduction Chronic pain is common, affecting about half of the general population. 1 It is a complex problem that requires a multidisciplinary approach to assessment and management. This holistic approach may involve the use of alternative therapies in addition to conventional treatment. The use of complementary medicine in the Received 13 March 2002; Revised 8 August 2002; Accepted 4 November Aberdeen Royal Infirmary and a University of Aberdeen, Aberdeen, UK. Correspondence to Dr Alison M Elliott, Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, UK; a.m.elliott@abdn.ac.uk general population is widespread and increasing, 2 with osteopathy, chiropractic, homeopathy, acupuncture and herbalism among the most popular therapies. A survey in 1993 estimated that 33% of the general population in the UK had used some form of complementary medicine in the past and that 10% had consulted a complementary practitioner in the previous year. 3 A high proportion of those who use alternative medicine have chronic pain. 4 A survey of non-orthodox practitioners in Great Britain found that 78% of consultations were for musculoskeletal problems, 5 and back pain and migraine have been shown to be predictors of alternative health care use. 6 The clinical efficacy of many alternative therapies in chronic pain is controversial, but some have been shown to have beneficial effects in particular disorders, such as 147

2 148 Family Practice an international journal chiropractic therapy for low back pain. 7 It has also been suggested that whilst complementary therapies may not decrease intensity, duration or frequency of pain, they can improve mood and subjective symptom ratings. 8 Complementary and alternative therapy is used frequently in conjunction with rather than as a substitute for conventional treatments. 5,6,9 It is unknown whether this is true for patients with chronic pain, who may be more inclined to seek alternatives therapies when conventional medicine is unlikely to provide a cure. As part of a large epidemiological study of chronic pain, we asked individuals about their use of conventional and alternative therapies. This paper presents the findings of this work. Methods Subjects and sampling Individuals from a previous population-based survey, 1 who agreed to participate in further research, were resurveyed using a postal self-completion questionnaire. The original study consisted of 5036 individuals, aged 25 years, registered with 29 general practices in the Grampian region of the UK. A total of 3605 (82.3%) individuals returned their questionnaires, of which 2422 (67.2%) agreed to participate in further research. Before sending out new questionnaires to these individuals, their GPs were asked to exclude anyone whom they felt should not be contacted again. This step was necessary because of the 4-year interval since the original survey. Two hundred and thirty-eight patients were excluded: 79 due to death, 90 because the individual had left the practice and five due to illness. No reason was given for 64 of the individuals excluded. Thus, 2184 individuals remained in the sample. Non-responders were sent a reminder with a replacement questionnaire at 2 and 4 weeks. The questionnaire The International Association for the Study of Pain defines chronic pain as pain that persists beyond normal tissue healing time, which is assumed to be 3 months. 10 The questionnaire identified individuals with chronic pain through two questions: (i) are you currently troubled by pain or discomfort, either all the time or on and off and (ii) have you had this pain or discomfort for more than 3 months? Individuals answering these questions in the affirmative were identified as having chronic pain and were asked to complete additional pain-related questions to determine site of pain, severity of pain and health care utilization. Respondents were asked to identify the site of their pain and were given a choice of back pain, neck and shoulder pain, headache, facial or dental pain, stomach ache or abdominal pain, pain in arms or legs, chest pain or other pain. Those with other pain were asked to specify a site. The severity of pain was assessed using the Chronic Pain Grade (CPG) questionnaire. This is a 7-item questionnaire that measures severity of chronic pain in terms of persistence, intensity and disability. Individuals with chronic pain can be assigned to one of four grades: grade I (low disability, low intensity), grade II (low disability, high intensity), grade III (high disability, moderately limiting) and grade IV (high disability, severely limiting). The questionnaire underwent rigorous validation during its design in the USA 11 and has been found to be reliable and valid in UK postal research of the general population. 12 The questions on health care utilization asked individuals with chronic pain how often (never, daily, weekly, monthly or yearly) they had seen a GP, a hospital specialist, a physical therapist or an alternative practitioner, e.g. aromatherapist or chiropractor, in the preceding year. Respondents were also asked how often they had taken prescription, non-prescription or alternative medicines, e.g. homeopathic medicine, in the preceding year. Sociodemographic details were also sought, and housing tenure was used to assess socio-economic status. Data analysis The questionnaire responses were entered into a Microsoft Access database and analysed using the SPSS for Windows statistical package. Basic descriptive statistics were used to describe which and how often different health care services were being used. Chi-square tests were used to test for associations between socio-demographic and other variables, and the Mantel Haenszel test was used to investigate trends across age groups. Results Of the 2184 questionnaires sent, 190 individuals had moved, 32 had died, 18 were unable to complete the questionnaire and an additional seven individuals were excluded by their GP during the study, and so were not approached again. Thus, 1608 questionnaires were completed and returned. This represents a corrected response rate of 83%. There was no significant difference in response rate between males (82.5%) and females (83.5%) (P = 0.550). The response rate increased with age from 74.5% in the years age group to 85.6% in the 79+ years age group (P 0.001). Of those who completed the chronic pain identification questions (n = 1560), 840 reported having chronic pain (53.8%). Of those who reported chronic pain, 516 (67.2%) had seen their GP in the preceding 12 months (Table 1). There was no significant difference between males (65.3%) and females (68.9%), but there was a significant difference between age groups (P = 0.003), with older individuals consulting the GP more commonly than younger individuals. Thirty-four per cent of respondents with chronic pain had seen a hospital

3 Chronic pain and the use of conventional and alternative therapy 149 TABLE 1 Practitioners consulted and medication taken in the last year by individuals with chronic pain by age and gender GP Hospital Physical Alternative Prescription Non-prescription Alternative specialist therapist therapist medicine medicine medicine n % n % n % n % n % n % n % Sex Male Female P = P = P = P = P = P P = Age group P = P = P = P = P P P = Total Percentages are of the total in each subgroup. specialist and 25.9% had seen a physical therapist in the preceding year. There were no significant differences between sexes or age groups. Alternative practitioners had been consulted by 18.2% of respondents with chronic pain, with significant differences between sexes and age groups. Females (21.7%) sought alternative therapy more frequently than males (14.3%) (P = 0.031) and younger individuals sought alternative therapy more frequently than older individuals (P = 0.040). Prescription and non-prescription medication was being taken by 58.4 and 57.4% of individuals with chronic pain, respectively (Table 1). Significantly more women than men were taking these preparations: 62.2% versus 54.1% for prescribed medication (P = 0.027) and 65.3% versus 48.4% for non-prescription medication (P 0.001). There was also a significant difference between age groups, with prescribed medicines being used more commonly by older age groups and non-prescription medication used more commonly by younger age groups (P < 0.001). Alternative medicines were being taken by 15.7% of individuals with chronic pain. Again, there were significant differences between sexes and age groups. Women (21.1%) were taking alternative medicines more commonly than men (10.0%) (P =0.001) and individuals in the middle of the age range were taking alternative medicine more commonly than the youngest and oldest age groups (P = 0.003). A substantial degree of overlap exists in the use of different services and medicines (Fig. 1). The majority of individuals with chronic pain who consulted an alternative practitioner (67.0%) did so in addition to seeing conventional practitioners and therapists. Similarly, most individuals taking alternative medicines (85.9%) were also taking conventional medicines. Most of the individuals who saw their GP for their pain did so on a monthly or yearly basis (97%) (Fig. 2). Of those who saw a hospital specialist, 77% did so annually. Those who saw a physical therapist tended to do so more frequently; 34% stated that they attended their therapist weekly. Of those taking prescription medication, 64.9% were taking it daily. Individuals taking nonprescription medication were taking it less frequently, 19.3% on a daily basis and 41.9% monthly. Nearly half of those taking alternative medicines (47.4%) were taking them on a daily basis. The GP was the most frequently consulted practitioner, irrespective of the site of pain (Fig. 3). Those with back pain or neck/shoulder pain consulted physical and alternative therapists more than individuals with pain elsewhere. The use of non-prescription and alternative medicines was highest among those with stomach pain compared with pain in other sites. When health care utilization by housing tenure was analysed, the most striking differences were in the use of alternative health care (Table 2). Individuals with chronic pain who own their home were more likely to use alternative medicine than those who rented their home; an alternative therapist was consulted by 13.1% of individuals who owned their home compared with 2.6% of individuals who rented their property from the council or a housing association. Alternative medicine was consumed by 10.9% of homeowners compared with 2.6% of those renting from the council or housing association. There were also significant differences between groups for consultation with a hospital specialist and consumption of prescription medicines. Those who owned or mortgaged their home were less likely to have seen a hospital specialist and less likely to have taken prescription medicines.

4 150 Family Practice an international journal FIGURE 1 The percentage of those with chronic pain who consulted conventional and alternative therapists increased with an increase in severity of pain (Table 3). As the chronic pain grade increased, so did the proportion of individuals taking prescription medication. The relationship between the CPG and consumption of medication is not so clear with non-prescription and alternative medicines. Individuals with grade II severity were considerably less likely to be using nonprescription medicines, and individuals with grade IV severity were much more likely to be using alternative medicines. To assess the apparent association between CPG and health care use further, odds ratios adjusted for age, Venn diagram of practitioners consulted and medication taken sex and housing tenure were calculated (Table 4). An increase in CPG is associated with a greater likelihood of consultation with conventional practitioners and consumption of prescribed medicines. Discussion Our study demonstrates that most individuals with chronic pain consult their GP more often than hospital specialists, physical therapists and alternative therapists. Consultation with a GP increased with age and severity of pain. Increasing severity of pain was also associated with increased attendance at hospital specialists,

5 Chronic pain and the use of conventional and alternative therapy 151 FIGURE 2 Frequency with which different practitioners were consulted and medication taken FIGURE 3 Site of pain, practitioners consulted and medication taken physical therapists and alternative therapists, and with increased consumption of prescription medication. The correlation between pain intensity and increasing health care use has been shown in other studies. 13,14 However, in our study, we have found a higher prevalence of alternative health care use amongst individuals with chronic pain than has been reported previously, irrespective of CPG or site of reported pain. In our study, alternative therapists were consulted by 18.2% of individuals and alternative medicine taken by 15.7%. These figures are considerably higher than the 5.9% of chronic pain patients seeking alternative care in

6 152 Family Practice an international journal TABLE 2 Housing tenure, practitioners consulted and medication taken Housing GP Hospital Physical Alternative Prescription Non-prescription Alternative tenure specialist therapist therapist medicine medicine medicine n % n % n % n % n % n % n % Owned/ mortgaged Council rented Privately rented and other P = P = P = P = P P = P = TABLE 4 TABLE 3 a Swedish population-based study. 13 However, this study asked about health care contact over a 3-month period rather than a year, which may partly explain such a large difference. We have also found that the majority of those with chronic pain who used complementary and alternative medicine did so in conjunction with conventional medicine. The concurrent use of conventional and alternative medicine has been demonstrated in previous studies 3,5,6 of the general population, but not in individuals with chronic pain. Our figures also suggest that a greater number of individuals with chronic pain Association of chronic pain grade, practitioners consulted and medication taken CPG GP Hospital Physical Alternative Prescription Non-prescription Alternative specialist therapist therapist medicine medicine medicine OR a (95% CI) OR a (95% CI) OR a (95% CI) OR a (95% CI) OR a (95% CI) OR a (95% CI) OR a (95% CI) P-value P-value P-value P-value P-value P-value P-value Grade I b Grade II 2.13 ( ) 1.85 ( ) 2.21 ( ) 1.06 ( ) 2.35 ( ) 1.49 ( ) 1.59 ( ) P P = P = P = P P = P = Grade III 2.70 ( ) 3.33 ( ) 1.63 ( ) 1.55 ( ) 2.50 ( ) 2.12 ( ) 1.45 ( ) P P P = P = P P = P = Grade IV 6.32 ( ) 7.93 ( ) 7.26 ( ) 2.01 ( ) 8.69 ( ) 0.79 ( ) 4.22 ( ) P P P P = P P = P a Odds ratio adjusted for age, sex and housing tenure. b Reference category. Chronic pain grade, practitioners consulted and medication taken CPG GP Hospital Physical Alternative Prescription Non-prescription Alternative specialist therapist therapist medicine medicine medicine n % n % n % n % n % n % n % Grade I Grade II Grade III Grade IV P P P P = P P P are seeking only alternative health care when compared with the general population. A Canadian populationbased study found that, over a 12-month period, 93.5% of those seeing an alternative practitioner had also seen a physician; 6 this compares with 67% of individuals with chronic pain in our study who were consulting conventional and alternative practitioners concurrently. The reasons why individuals with chronic pain use alternative medicine, either alone or in conjunction with conventional treatment, are not known. Some studies of the general population have found that the use of alternative therapy does not indicate dissatisfaction with

7 Chronic pain and the use of conventional and alternative therapy 153 conventional medicine. 3,5 However, one study did find that users of alternative therapy were significantly less satisfied with conventional treatment compared with non-users and that one in four individuals using alternative medicine did so to avoid the side effects of conventional treatment or because conventional treatment had failed to cure their problem. 9 We found some very interesting socio-demographic differences in this study. There were no significant differences in consultations with traditional health professionals between men and women. This finding is similar to a health care utilization study in Sweden, 13 but is contrary to work looking at levels of consulting amongst individuals with chronic widespread pain in Manchester, which found that females were more likely to have consulted than males. 15 We found that women were more likely to have used prescription and non-prescription medicine than men, and this finding is in line with previous work which reported that women were more likely to use analgesics than men. 13 We also found that women were more likely to see an alternative therapist and use alternative medicines than men. This is perhaps not a surprising result and suggests that women are more open to alternative techniques than their male counterparts. A number of differences in consultation patterns and medicine use by age were identified, and our findings followed a broadly recognized pattern. Older age groups are more likely to consult their GP and use prescription medicines than younger age groups. The younger age groups were found to be less likely to consult traditional health professionals, relying instead on alternative treatments and over-the-counter medicines. This change in the pattern of health care utilization may have important implications for future services. As well as the age and sex associations, we found that socio-economic class was an important factor in health care use. In our study, higher socio-economic class was associated with consultation with alternative therapists and consumption of alternative medicine, with less reliance on prescription medication. Higher socio-economic class and higher levels of education are known to be associated with use of alternative health care. However, research suggests that, rather than a lack of interest among lower socio-economic groups, the problem is a lack of access. 16 A recent study in the USA found that past use and desired future use of complementary medicine was comparable at three ambulatory clinic sites despite wide differences in socio-economic status and ability to pay. 17 The difference in prescription medication consumption between socio-economic classes is interesting and reflects the findings of a previous study which showed that white collar workers were less likely to use prescribed analgesics and sedatives. 13 The reasons for this are not known, but it has been postulated that higher levels of education are associated with greater awareness of available medication. The use of complementary therapy is increasing, particularly for those with pain problems. 5 Yet, in our study, the use of alternative therapy by patients with chronic pain was similar to the 1-year prevalence found in a national study of the general population in the UK. 18 There is increasing provision of alternative therapies by GPs and pain management clinics, with ~40% of general practices in the UK providing some complementary medicine services. 2 However, alternative therapy is usually personally funded (in the UK) and expensive. A recent UK survey showed that ~4 billion pounds per year was spent on complementary medicine outside the NHS. 2 These observations raise questions about the current accessibility of alternative therapies for individuals with chronic pain. The major strengths of our study were the large number of individuals recruited, the high response rate and the population base of the sample. There were also some limitations to the work. First, the study was conducted within a single region of the UK, and this confinement within a specific geographical area may be a source of bias. It may be that some of our findings reflect the availability of services in this area rather than individual preferences for different types of treatment. Grampian differs from other parts of the UK in a number of ways. It is a relatively affluent part of the UK with comparatively low levels of deprivation. It also has a large number of rural areas in comparison with other regions in the UK. Compared with previous research in less affluent UK areas, our findings appear to be lower than some previous estimates of consultation levels 15 and higher than others. 19 However, differences in the populations studied and the time frames analysed make direct comparison difficult, and we need to be cautious about extrapolation of our results to other populations. Secondly, there is a lack of comparative data as only individuals with chronic pain were asked to complete questions about use of conventional and alternative health care, and the number of individuals seeking alternative care was small. Finally, the reasons for use of alternative health care, and in particular the reasons for the use of alternative health care alone, were not explored. This study shows that a large number of individuals with chronic pain are using alternative therapies alone. It is not known whether this is due to dissatisfaction with conventional treatment or whether these individuals would benefit from a more comprehensive management programme. Further research will be necessary to elucidate this. Acknowledgements We thank the patients and general practices for their continued support of this study, and Netta Clark, Susan Robertson and Hilary Selbie for helping to collect and enter the data. This project was funded by a grant from the education and research trust of the Association

8 154 Family Practice an international journal of Anaesthetists of Great Britain and Ireland. BHS is supported by an NHS R&D Primary Care Career Scientist Award, funded by the Scottish Executive, Department of Health. References 1 Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WC. The epidemiology of chronic pain in the community. Lancet 1999; 354: Rees L, Weil A. Integrated medicine. Br Med J 2001; 322: Zollman C, Vickers A. Users and practitioners of complementary medicine. Br Med J 1999; 319: Astin JA. Why patients use alternative medicine. J Am Med Assoc 1998; 279: Thomas KJ, Carr J, Westlake L, Williams BT. Use of non orthodox and conventional health care in Great Britain. Br Med J 1991; 302: Muhajarine N, Neudorf C, Martin K. Concurrent consultations with physicians and providers of alternative care: results from a population based study. Can J Public Health 2000; 91: Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990; 300: Malone MD, Stube MJ, Scogin FR. Meta analysis of non medical treatments for chronic pain. Pain 1998; 34: Palinkas LA, Kabongo ML. The use of complementary and alternative medicine by primary care patients. A SURF*NET study. J Fam Pract 2000; 49: International Association for the Study of Pain. Classification of chronic pain. Pain 1986; Suppl 3: S1 S Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992; 50: Smith BH, Penny KI, Purves AM et al. The Chronic Pain Grade questionnaire: validation and reliability in postal research. Pain 1997; 71: Andersson HI, Ejlertsson G, Leden I, Schersten B. Impact of chronic pain on health care seeking, self care and medication. Results from a population based Swedish study. J Epidemiol Community Health 1999; 53: Chrubasik S, Junck H, Zappe HA, Stutzke O. A survey on pain complaints and health care utilisation in a German population sample. Eur J Anaesthesiol 1998; 15: Macfarlane GJ, Morris S, Hunt IM, Benjamin S, McBeth J, Papageorgiou AC, Silman AJ. Chronic widespread pain in the community: the influence of psychological symptoms and mental disorder on healthcare seeking behaviour. J Rheumatol 1999; 26: Smith BH, Hopton JL, Chambers WA. Chronic pain in primary care. Fam Pract 1999; 16: Wolsko P, Ware L, Kutner J et al. Alternative/complementary medicine: wider usage than generally appreciated. J Alter Complement Med 2000; 6: Ernst E. The role of complementary and alternative medicine. Br Med J 2000; 321: Waxman R, Tennant A, Helliwell P. Community survey of factors associated with consultation for low back pain. Br Med J 1998; 317: