14RC2 - Aguilar. Social Impact of Pain. José L. Aguilar. The Clinical and Social Context of pain. Costs of Pain - 1 -

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1 14RC2 - Aguilar Social Impact of Pain José L. Aguilar Anesthesia Department and Pain Clinic, Hospital Son Llatzer Palma de Mallorca, Spain This Refresher Course provides a review of the current data from the European Pain IASP Chapters (EFIC), and predicts future strategies for anaesthesiologists, pain clinicians and other healthcare professionals, to assist them understand and cope with both the effects and consequences of pain in our society. The Clinical and Social Context of pain Pain is an inherent phenomenon that combines physical and emotional elements; it affects a person s capacity to relate with his peers and the environment and has a high impact within society. The European Federation of the International Association for the Study of Pain Chapters (EFIC) published its Declaration on Pain in 2001: Pain is a major healthcare problem in Europe. Although acute pain may reasonably be considered a symptom of disease or injury, chronic and recurrent pain is a specific healthcare problem, a disease in its own right [1]. This publication called on national governments and EU Institutions to increase the level of awareness of the societal impact of pain. Ten years on from the EFIC Declaration on Pain, national and EU activity to create policies to address the document s recommendations has been very limited. In the interim, basic and clinically based scientific research has demonstrated the feasibility of development of pathways to address the pain associated with many types of acute and chronic conditions. Unfortunately, health care systems currently do not guarantee general access to these developments. According to the 2007 Eurobarometer survey on Health in the European Union [2], almost one third of respondents experienced musculoskeletal pain which affected their day-to-day life. The burden of suffering that pain imposes on individuals and the enormous costs that society has to bear, not only by healthcare systems but also the social, economic and employment sectors only illustrate the urgency for European governments and the EU Institutions to act and to prioritise the societal impact of pain on their policy agenda. Chronic pain presents a major challenge to the citizens and the economy of Europe one that is likely to worsen as the population ages. A 2006 survey showed that one in five Europeans suffer from chronic pain, with most experiencing it for over two years although cases were recorded whereby some people had been enduring chronic pain, associated with its attendant problems, for 20 years or longer [3]. Chronic pain, a burden in itself, may also result in physical and psychological disability and is associated with serious co-morbidities and psychological disorders such as anxiety and depression [4]. The negative impact of chronic pain frequently extends beyond the sufferer to affect loved ones and dependents. Costs of Pain The quantification of the economic costs of pain require an appraisal of a range of diverse elements in a manner in which clinicians are not normally accustomed to do [5]. There are many different aspects that require consideration. The derived costs of pain can be tangible or intangible: - 1 -

2 Tangible costs of pain: For the individual: Cause of pain/aetiology Aftermath of pathology Workplace absence due to pain (sick leave or temporary inability to work) Loss of income and costs of treatment of pain For Society: Active/Passive population Social coverage Social loss of income: Society is unable to generate an income through individuals who experience pain which results in sick leave or long or short term disability Costs of pain treatment Burn-Out of healthcare professionals and the patient s relatives and workplace colleagues or superiors through the support they provide and the burden they shoulder on behalf of the patient) Intangible costs of pain: Suffering Emotional impact Loss of self-esteem Interpersonal relationships (partner and wider family) social and work environment Costs of Pain Treatment: Direct costs: Personal Pharmacy Prosthesis and disposable Recoup the investment in Medical Technology Indirect costs: Auxiliary (advisory among health professionals) Structural (architecture, cleaning, water, electricity, etc.) In the doctoral thesis by the author of this Refresher Course [6], it was estimated that the costs associated with pain approximated to 2.5% of the Gross Domestic Product (GDP) of Spain at that time (1990). Pain is more than a burden on individuals and their families alone. Chronic pain costs Europe billions of euros: perhaps as much as 300 billion across the EU [7], or around 1.5-3% of GDP [8,9]. The direct cost of chronic pain to healthcare systems is significant. Taking back pain as an example, consultations with healthcare professionals make up the largest share of overall healthcare system costs which are estimated at 187 million for Belgium [10] $368 million ( 289 million) for the Netherlands [11] and over 1.6 billion ( 1.9 billion) for the UK [12]

3 According to new survey data from France, Germany, Italy, Spain and the UK: People with severe pain visited healthcare professionals an average of 13 times in the previous six months, double the average number of visits made by the general adult population Twenty five percent of those with severe pain had visited an emergency room in the past six months and 22% had been hospitalised due to their pain more than double the percentage for the general population in both instances. Inappropriate and ineffective management and treatment, which can generate repeat visits to primary care and referrals to specialists, have been highlighted and are important drivers of avoidable healthcare costs. However, while direct costs are high, it has been estimated that nine-tenths of the burden of pain may fall on the broader society: employers, taxpayers (through welfare payments, for example), people with pain and their families [11]. The relative scarcity of consistent data on the indirect costs of pain highlights a need for more systematic research to gain a more accurate picture of the current impact of chronic pain on a national and Europe-wide basis. However, the scale of these indirect costs greatly exceeds the direct costs of managing pain and suggests that even small increases in the effectiveness of pain management could reap large economic rewards. Costs for diagnosis and therapy represent 15-20% of total costs associated with pain[13] Pain as a Sociopathy Chronic widespread pain is a prominent symptom in our society. Chronic pain can cause significant disability and is associated with co-morbidities and psychological disorders such as anxiety and depression. Pain has a profound impact on quality of life and can have physical, psychological and social consequences. Chronic pain can be caused by a variety of physical or psychological factors. Physical causes include musculoskeletal, vascular and neurological conditions as well as injury to organs and tissues from surgical interventions or other diseases, such as cancer. Chronic pain can be nociceptive, neuropathic or a combination of both. Nociceptive pain is associated with tissue damage. Neuropathic pain occurs when nerves, or part of the nervous system malfunction. If pain has a neuropathic element it can be resistant to some commonly used treatments and may require a different approach [14]. The most common location for pain is the back. According to research conducted in five European countries in 2010, back pain accounts for 70% of cases of severe pain, 65% of moderate pain and over half the cases of mild pain [13]. The Pain Proposal survey of people with chronic pain, listed back problems as the most common cause of chronic pain, followed by joint pain and neck pain. Most common causes of chronic pain: 55% Back problems 46% Joint pain 34% Neck pain 22% Headache 18% Arthritis 16% Migraine 13% Fibromyalgia 11% Neuropathic 10% Surgery/medical procedures 7% Visceral (from internal organs) 4% Diabetes 2% Cancer 1% Shingles (post herpetic neuralgia) - 3 -

4 The Pain Proposal survey reveals [13]: 27% of people with chronic pain feel socially isolated and lonely because of their pain 50% worry about the effect of their chronic pain on their relationships 29% worry about losing their job 36% say their chronic pain has a negative impact on their family and friends On average, people with chronic pain must wait 2.2 years between seeking help and diagnosis, and 1.9 years before their pain is adequately managed A quarter (26%) of people wait 1-5 years to receive a diagnosis or reason for their pain and a further 11% wait longer 38% of people with chronic pain report that their pain is not adequately managed People with chronic pain make an average of nearly seven visits to healthcare professionals a year, with 22% making 10 visits or more Nearly half those surveyed were dissatisfied with the time it took to reach a diagnosis (49%), the time to get adequate management of their pain (48%) or the number of visits to the doctor taken to achieve adequate management (50%) Most patients that attend pain consultations, experience a series of signs and symptoms, which are interrelated, due to biochemical contributions from similar neurotransmitters. Pain, appetite, sleep and mood, depend on a series of neurotransmitters (serotonin, noradrenaline, endorphins, dopamine). When present at adequate levels these maintain the individual in an emotional-physical balance but when present at low levels (based on the specific order mentioned above) cause more pain, anorexia/bulimia, drowsiness, depression or sadness respectively. Conversely, less pain/hyperalgesia, anorexia/bulimia, euphoria or mania are experienced if the levels are elevated. When these symptoms are combined they create a very high rate of medical consultation under the collective heading of pain, and often, it can be difficult to differentiate between them. The term it hurts is sometimes a manifestation of actual pain, but sometimes, expresses frustration and lack of enthusiasm, sleep disturbances or loss of appetite. In reality this can represent personal and social dissatisfaction associated with their relationship with their environment, because of the psychological state of the individual/patient. In this context use of antidepressants outside their usual clinical indication (tricyclic, selective serotonin reuptake inhibitors SSRI, and non selective ones NSRI (serotonin and noradrenaline)) are frequently prescribed drugs for this indication in the Balearic Islands [15]. Pain and Work Activity Physical exercise (of any intensity) increases the levels of neurotransmitters, and this has led to the long-standing recommendation to mobilise when there is pain, especially lumbar pain [16]. We know now that: 21% of Europeans with chronic pain are unable to work at all as a result of their chronic pain People with chronic pain felt their pain negatively affected their ability to do their job for more than a quarter (28%) of the time they were at work Of those that are able to work, 61% state their employment status is directly affected by their condition Studies have indicated that people with chronic pain may be seven times more likely than other individuals to leave a job because of ill health and are less likely to return to employment: as few as 10% ever return to work according to one estimate [17,18]. There are examples from within Europe that show it is possible to improve services, boosting effectiveness and improving outcomes for people with chronic pain, while also cutting unnecessary expenditure. For instance, a pain clinic in the UK pioneering multidisciplinary pain management techniques increased patient satisfaction by 75% and generated cost savings of 35% per patient. However, the demonstration of such beneficial results as this remain fairly isolated in Europe despite the positive return on the investment in improvements in pain management brought by such examples. A frequent obstacle to the broader implementation of such strategies is fragmented budgeting and management. Better coordination within health services, between levels of government (central, regional and local) and between government departments (e.g. health and welfare) will be critical to realising these savings on a larger scale. Learning from innovative approaches to budgeting already being practised in some European countries should be a priority

5 The economic case for prioritising pain management is compelling. Tackling inefficiencies in pain management can deliver savings to health budgets and, given the direct relationship between chronic pain and both incapacity and workforce productivity, generate a boost to European economies in the near to medium term. Ineffective pain management generates avoidable costs Much of the available evidence indicates that ineffective or inefficient management of pain is responsible for a significant proportion of costs. A UK-based study in 2002 estimated there were 4.6 million primary care consultations per year involving chronic pain. This consultation time amounted to employment of 793 full-time primary care physicians at a cost of approximately 69 million ( 82 million). The study highlighted inadequate management with use of ineffective or poorly tolerated medication as a major factor in the number of consultations [19]. The lack of clear management pathways for those with chronic pain also plays a significant role in the accumulation of costs. The care of people with chronic pain can involve a wide range of medical specialists, resulting in a fragmented approach to management, where no one group is accountable for improvements or outcomes. There is inconsistency in the pattern of referrals from primary to secondary care with over a third (36%) of primary care doctors lacking confidence in knowing when to refer a person with chronic pain to a specialist and to whom. Countries such as Norway, in which a significantly higher than average proportion of primary care physicians reported uncertainty determining which specialist to refer a patient to, also showed relatively high rates of early referral. The findings suggest that inappropriate referrals to specialists, a key driver of healthcare costs, may be happening around Europe. As a result of this, direct costs could be higher than they need to be. Relatively high levels of uncertainty over referral and high rates of early referral seem to correspond to relatively low levels of pain management training for primary care professionals. This indicates that education has a role to play in controlling the direct costs of pain. Indeed 85% of primary care physicians express a desire for more training to equip them better to manage chronic pain patients. Strategies for the future The pathway through the healthcare system can be lengthy, convoluted and inefficient for people with chronic pain, with conflicting advice and treatment approaches resulting in high use of healthcare services. The Pain Proposal survey found that a quarter (26%) of people were forced to wait between one and five years to receive a diagnosis (or reason) for their pain and a further 11% waited even longer. Nearly half those surveyed were dissatisfied with the time it took to reach a diagnosis (49%), the time to obtain adequate management of their pain (48%) or the number of visits to the doctor required to achieve adequate management (50%). Overall, the number of visits by people with chronic pain to a healthcare professional were high - an average of nearly seven visits a year, with 22% having to make 10 visits or more. Despite this, a significant proportion, 38%, still reported that their pain was not adequately managed. The subjective nature of pain can lead others to doubt its severity and public views of people with chronic pain are not always sympathetic. The Pain Proposal survey shows that 41% of those living with chronic pain feel that people often doubt the existence of their condition. Despite the fact that 80% of people living with chronic pain are keen to be active members of society, 25% have been accused of using their chronic pain as an excuse not to work and only 27% feel their employer recognises and understands their chronic pain Additionally, two-thirds (62%) of those surveyed feel that public understanding and awareness of chronic pain is low. There is a need for improved communication between patients and healthcare professionals and for evidence-based resources for people with chronic pain and their families to ensure effective management

6 Cost Utility Analysis (CUA) Cost Utility Analysis is more helpful in pain CUA is a method of analysing the economic value of a method of treatment based on the assessment of preferences or utilities (benefits) made by the individuals (patients) What is the concept of utility? The preference or assessment that the citizen has with respect to a health status Once utilities are determined, Cost/Utility ratios are calculated and compared in everyone of the alternatives Finally the lower ratio cost/utility can be chosen An example: Rogerson MD, Gatchel RJ, Bierner SM. A cost utility analysis of Interdisciplinary Early Intervention versus Treatment as usual for high-risk acute low back pain patients. Pain Practice 2010; 10: A randomized controlled trial by McBeth and colleagues [20] assesses whether Telephone-delivered Cognitive Behaviour Therapy (TCBT) alone, exercise alone, combined TCBT and exercise, versus usual care are effective and cost-effective in the treatment of chronic widespread pain. In their article, the researchers note that no drugs are currently approved in the United Kingdom for chronic, widespread pain, the cardinal feature of fibromyalgia. In addition, none of the 3 drugs currently approved in the United States (duloxetine hydrochloride, milnacipram hydrochloride, and pregabalin) adequately control the multiple symptoms of fibromyalgia. Current guidelines recommend pharmacological, physical, and psychological therapies, although the value of individual therapies is unclear. Traditional Cognitive Behaviour Therapy (CBT) has shown promise for fibromyalgia, and TCBT is potentially more acceptable, accessible, and cost-effective. That is an example of integration of ICT (Information and Communication Technologies) as a way of optimizing resources and increasing efficiency (cost/effectiveness), in the relief of societal pain. Key Learning Points The burden of suffering that pain imposes on individuals and the enormous costs that society has to bear not only by healthcare systems but also the social, economic and employment sectors only serves to illustrate the urgency with which European governments and the EU Institutions need act and to prioritise the societal impact of pain on their policy agenda. Chronic pain is a burden in itself and may result in physical and psychological disability associated with serious co-morbidities and psychological disorders such as anxiety and depression. The negative impact of chronic pain frequently extends beyond the sufferer to affect loved ones and dependents. Chronic pain costs Europe billions of euros: perhaps as much as 300 billion across the EU, or around 1.5-3% of the Gross Domestic Product Diagnostic and treatment costs represent 15-20% of total costs associated with pain The most common location for pain is the back Information and Communication Technology is a tool for optimizing resources and increasing efficiency (cost/effectiveness), in the relief of societal pain

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