Epidemiology and cost of chronic pain Dr Beverly Collett Consultant in Pain Medicine University Hospitals of Leicester Regional Advisor Treasurer of IASP
Epidemiology Chronic pain is defined differently, according to survey. Chronic pain = Pain daily for 3 months in the last 6 months (Blyth et al. 2001) Chronic Pain = Presence of pain and pain started > 3 months ago (Elliott et al. 1999) Chronic pain = Pain lasting 6 months (Eriksen et al 2003) Chronic Pain = Pain due to illness > 6 months; pain last month; pain several times a week; pain intensity 5 (Breivik et al. 2006)
Aim Estimate the prevalence of chronic pain conditions across Europe Understand and quantify the sources and causes of chronic pain; Explore the demographics of sufferers; Explore the impact of pain on sufferers quality of life Understand current treatment practices & levels of satisfaction Explore the attitudes of sufferers toward and experiences with pain
Pain in Europe Breivik et al. European Journal of Pain 2006;10:287-333 Screening interviews were conducted: 3,800 respondents in each country for the first six countries 2,000 respondents in each country for the next ten countries The interviews were conducted via: CATI (computer assisted telephone interviewing); random digit dialing to contact a random sample of respondents. Purpose of screening: determine the prevalence of chronic pain across Europe identify > 300 chronic pain sufferers per country for detailed questionnaire Chronic pain defined as: Adult >18 years; suffered from pain due to illness or medical condition > 6 months; experienced pain within the past month; experienced pain at least several times a week; rates intensity of pain as 5 or higher on a 1-10 scale where 1 = No pain at all and 10 = The worst pain imaginable; and has not participated in medical studies or studies for pain medication.
Pain In Europe Method for prevalence estimation: Country Phone Screen Structured Phone Interviews Country Phone Screen Structured Phone Interviews UK 3,800 300 Netherlands 3,197 300 France 3,846 300 Germany 3,832 302 Italy 3,849 300 Spain 3,801 301 Poland 3,812 300 Sweden 2,563 300 Norway 2,018 304 Denmark 2,169 303 Belgium 2,451 301 Finland 2,004 303 Ireland 2,722 300 Switzerland 2,083 300 Austria 2,004 303 Israel 2,244 322 Total 46,394 4839 Breivik et al. 2006
Pain in Europe Prevalence of chronic pain Europe: 19% N= 46 394 adult respondents Spain Ireland UK France Switzerland Denmark Israel Germany Netherlands Sweden Finland Austria Belgium Italy Poland Norway 12 13 13 15 16 16 17 17 18 18 19 21 23 26 27 30 Number of respondents answ ering: Spain = 3801 Ireland = 2722 UK = 3800 France = 3846 Sw itzerland = 2083 Denmark = 2169 Israel = 2244 Germany = 3832 Netherlands = 3197 Sw eden = 2563 Finland = 2004 Austria = 2004 Belgium = 2451 Italy = 3849 Poland = 3812 Norw ay = 2018 0 10 20 30 40 50 60 70 80 90 100 % respondents Breivik et al. 2006
Age and sex of 4839 responders suffering from chronic pain Fig. 2a. Age and sex of 4839 responders suffering from
Duration of chronic pain of intensity 5 or more on a 1 10 NRS pain intensity scale. Fig. 2a. Age and sex of 4839 responders suffering from
Body locations and respondents opinions of the cause(s) of their chronic pain.
Pain in Europe: Intensity of pain and tolerance for pain in Europeans: % respondents rating pain as 5 10 on a 10-point numerical rating scale 1 (n = 4839) Tolerance level for more pain (n = 4785) Nine 7% Ten 7% Five 25% My pain is so severe, I could not tolerate any more I could tolerate a little more pain 31 47 Eight 20% Seven 19% Six 22% I could tolerate somewhat more pain I could tolerate a lot more pain 4 18 1 Respondents with scores of 1 4 were not eligible to participate in the study 0 10 20 30 40 50 60 70 80 90 100 % respondents Breivik et al. 2006
Pain in Europe: Impact of pain on daily activities: Maintaining relationships with family and friends (n = 4786) Driving (n = 3874) 5 22 23 24 Having sexual relations (n = 3708) 19 24 Maintaining an independent lifestyle (n = 4780) Working outside home (n = 4228) 6 24 32 29 No longer able Less able Attending social activities (n = 4675) 14 34 Walking (n = 4822) 7 40 Household chores (n = 4658) 12 42 Lifting (n = 4784) Exercising (n = 4615) 23 23 49 50 Sleeping (n = 4794) 9 56 0 10 20 30 40 50 60 70 80 90 100 % respondents Breivik et al. 2006
Pain can devastate lives 30 25 25 24 20 16 18 15 10 5 0 Lost Job Changed Job Responsibilities Changed Jobs Entirely Been Diagnosed with Depression
Pain In Europe: Patients beliefs about their pain - % (score 1-2 on scale 1-5) My pain is just part of my medical condition (n = 4604) 75 I feel tired all the time (n = 4763) 50 My pain keeps me from thinking or concentrating clearly (n = 4755) 44 Being in pain makes me feel helpless (n = 4770) I cannot function normally (n = 4758) 40 43 I cannot remember what it feels like not to be in pain (n = 4655) 36 I feel much older than I really am (n = 4737) 32 I feel alone with my pain (n = 4759) 28 I am in too much pain to take care of mysels and others as well as I would like to (n = 4719) 26 Some days the pain is so bad, I want to die (n = 4696) 16 0 20 40 60 80 100 % respondents Breivik et al. 2005
Pain in Europe: % who had tried physical therapy UK 15 Ireland 26 Number of respondents: France Germany Italy Spain Poland Sweden Norway Denmark Finland 2 6 15 18 23 38 41 47 55 UK = 292 Ireland = 296 France = 289 Germany = 301 Italy = 295 Spain = 288 Poland = 288 Sweden = 296 Norway = 302 Denmark = 301 Finland = 303 Netherlands = 299 Belgium = 297 Austria = 301 Switzerland = 297 Israel = 294 Netherlands 52 Belgium 17 Austria Switzerland 24 25 Israel 33 0 20 40 60 80 100 % respondents Breivik et al. 2006
Pain in Europe: Current use of pain medicines by country % UK Ireland 23 32 19 50 13 5 8 12 38 3 Number of respondents: France Germany Italy Spain Poland Sweden Norway Denmark Finland 25 27 24 38 49 54 54 19 68 71 8 4 36 50 11 13 38 20 1 8 3 8 22 9 2 4 2 6 26 6 2 8 28 7 6 26 7 4 45 8 1 16 NSAID Weak opioid Strong opioid Paracetamol COX-2 inhibitor 11 UK = 146 Ireland = 129 France = 146 Germany = 124 Italy = 90 Spain = 164 Poland = 106 Sweden = 119 Norway = 159 Denmark = 142 Finland = 177 Netherlands = 99 Belgium = 148 Austria = 119 Switzerland = 120 Israel = 135 Netherlands 36 14 5 11 16 European averages (n = 2063): Belgium Austria Switzerland Israel 42 58 48 53 15 18 5 7 5 14 3 2 5 12 33 4 4 13 36 13 NSAIDs = 44% Weak opioids = 23% Paracetamol = 18% COX-2 inhibitor = 6% Strong opioids = 5% 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 % respondents Breivik et al. 2006
Pain in Europe: Classes of medications currently used for pain, based on total respondents taking a prescription medicine (n = 2063) Beta/CC blocker 1 Muscle relaxant 1 Anti-epileptic 2 DMARD/steroid 2 Triptan 3 Tricyclic/SSRI/SNRI 3 Barbiturate/ergotamine 3 Strong opioid COX-2 inhibitor 5 6 Paracetamol 18 Weak opioid 23 NSAID 44 0 10 20 30 40 50 60 70 80 90 100 % respondents Breivik et al. 2006
Pain in Europe: % of patients reporting inadequate pain control UK 37 Number of respondents: Ireland France Germany Italy Spain Poland Sweden Norway Denmark 29 29 33 46 41 45 43 49 61 UK = 283 Ireland = 272 France = 297 Germany = 294 Italy = 275 Spain = 294 Poland = 288 Sweden = 252 Norway = 298 Denmark = 267 Finland = 300 Netherlands = 274 Belgium = 298 Austria = 293 Switzerland = 299 Israel = 308 Finland 27 Netherlands 56 Belgium Austria 31 61 Percentage of total population reporting inadequate pain control (n = 4627) = 40% Switzerland 54 Israel 40 0 10 20 30 40 50 60 70 80 90 100 % respondents Breivik et al. 2006
These are the most common causes given for not receiving pain treatment.
Most frequently stated attitudes and beliefs of respondents about pain treatments.
Percentage of respondents who agreed somewhat or completely with the statements
Most common types of health care professionals currently treating the pain of the respondents with chronic pain
Comparison: Economic and Social Impact Canada: 49% of patients were unable to attend social/family events due to their chronic pain; 61% were unable to participate in their usual recreational activities; 58% were unable to carry out their usual daily activities at home Australia: 11% of males and 13.5% of females reported some degree of interference with daily activities
Comparison: Economic and Social Impact Europe: the mean number of days off work per year due to pain was 15 60% of people said they were less able or unable to work outside home 20% had lost their job due to pain Canada: the mean number of days off work in a period of a year due to chronic pain was 9.3 Australia: Fewer chronic pain respondents were in full-time work (30.9% vs. 42.8%)
Patient/Doctor Relationship Patients views on their relationship with their physician varies: In Denmark, 33% of patients were not satisfied with the examinations carried out in connection with their pain condition 28% of people across Europe believed their doctor did not know how to control their pain In Canada, 77% expressed satisfaction with their doctor s care, even though the mean pain intensity was 6.3 In Japan, 88% satisfaction with physician, despite 77% had inadequate pain control
Comparison: Attitudes to Treatment Various levels of satisfaction with treatment were reported within the studies: In Europe, 41% of respondents felt that their pain medicines for only somewhat effective. In the U.S. 42% of patients said their current medication was not completely effective or very effective In Japan 77% of people said their pain was not adequately controlled In Canada 36% of respondents reported their pain treatment as very effective
Personal Cost 7.8 million people live with chronic pain in UK 13% UK population have chronic pain 1 in 4 households affected by chronic pain in every parliamentary constituency 25% lose their jobs 22% of patients with pain develop depression 23% thought that their doctor did not know how to treat their pain
Pain 1.6 million adults have back pain 1 million women have pelvic pain (38/1000) Incidence of persistent pain 5 years after injury 62.7% Post-surgical pain 5%-65% Impact of neuropathic pain=heart disease or severe mental illness Chronic pain associated with increased 10-year mortality
Cost of pain in Primary Care Chronic pain is presenting condition in 22% of primary care consults Patients with chronic pain consult GPs 5 times more frequently 4.6 million GPs appointments per year = 793 whole time GPs = 69 million
Pain in the Older person Affects 50% of community living older persons Affects >80% of nursing home residents (Ferrell1995,Gibson 2001) Affects 10 million elderly patients in UK (Patients Association) Tend to under-report pain Assessment can be difficult Impairs quality of life
Pain in older person OA, RA, CVA, diabetes, post-herpetic neuralgia, cancer, spinal canal stenosis Co-morbidity common Need multidisciplinary approach Multiple drug interactions Increased adverse effects
Pain and culture South Asian 3 times more common Poor housing Heavy manual work
Pain in children 15% (8%-25%) of children have persistent pain Girls more pain than boys Incidence peaks at 14 years 25% of those report distress and disability
Pain in children Sickle cell crisis Headache Abdominal pain Musculoskeletal pain Menstrual pain 5% to 14% girls regularly miss school
Cost of children s pain 8,000/ year for adolescent attending PMP 3840 million /year nationally Parents lose work Parent give up work to care for child Cost of investigations Cost of failed treatment
Economic cost 70% people living with chronic pain are of working age 3.8 billion spent per year on IB for those with chronic pain Pain is second most common reason given by claimants of IB 584 million on prescriptions for analgesics Cost of back pain was 12.3 billion (22% of UK health expenditure) - mainly due to work days lost. 49% of those diagnosed with chronic pain take time off work.
Economic cost 2.468 million IB claimants: 17% MSK pain Weekly costs 27 million (DWP Feb 2009) DWP: 40% new IB claimants had MSK pain MSK pain: direct costs 2% GDP of Europe