RESEARCH - Chronic pain is major healthcare problem, needs to be taken more seriously

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Chronic pain is major healthcare problem, needs to be taken more seriously

Rheumawire

Sep 12, 2005

Zosia Chustecka

Oslo, Norway - A huge European survey, involving nearly 50 000 respondents,

has shown that one in five adults suffers from chronic pain [1]. About half

said they were in constant pain, and about one third said the pain was

severe. Very few of these individuals (2%) have ever seen a pain specialist,

and nearly half reported inadequate pain management.

" We have documented that chronic pain is a major healthcare problem in

Europe and needs to be taken more seriously, " conclude the authors, headed

by Dr Harald Breivik (University of Oslo, Norway), on behalf of the Opioids

and Pain European Network. The results of the survey are published online

August 8, 2005 in the European Journal of Pain. The survey was funded by

Mundipharma International.

For the purposes of the survey, chronic pain was defined as lasting for six

months or more, with pain experienced in the past month and several times

during the past week. The last episode of pain had to have an intensity of 5

or more on a 10-point numeric rating scale (where 1=no pain, 10=worst pain

imaginable). Of 46 394 adults randomly approached by telephone, 19% were in

this category.

" We feel confident that our definition excludes those with mild pain that

most people would consider more a nuisance than a chronic disability, " say

the authors.

The 4839 respondents with chronic pain were subjected to in-depth

interviews. In most cases, the pain had lasted for more than two years, and

about 20% said they had been in pain for 20 years or more. Many were unable

to manage daily activities. " Perhaps the most notable results were that

around two thirds of people were less able or unable to sleep because of

their pain, and about half found walking and household chores difficult, "

the authors comment. About 40% said their pain made them feel helpless and

they could not function normally, and around 20% had been diagnosed with

depression as a result of their pain.

Over one third of respondents said they could not remember what it was like

not to be in pain, the researchers note, and 16% said that on some days,

they feel their pain is so bad that they want to die.

Osteoarthritis and RA most common causes

The most common cause of pain was osteoarthritis and rheumatoid arthritis,

together accounting for 42% of respondents. Next was chronic pain from

deteriorated or herniated disks, degeneration or fractures of the spine

(20%), followed by trauma or surgery (15%). Migraine headaches accounted for

less than 10%, and nerve damage and whiplash for 4% each. Only 1% of

respondents gave cancer as the cause of their pain; 12% said they didn't

know the cause of their pain.

Most of the respondents (70%) were being seen for their pain by general

practitioners. Only 9% were being seen by rheumatologists, while 27% were

seen by orthopedists/orthopedic surgeons, 10% by neurologists/neurosurgeons,

7% by internists, and 6% by physiotherapists. Overall, only 2% of

respondents were currently being seen by a pain specialist, although 23% had

been seen by a pain specialist at some time in the past. However, further

probing into this question showed wide variation across the different

nations. More than 40% of respondents in Israel, France, and Italy said that

they had been seen by a pain specialist, compared with only 8% in Norway,

10% in Germany, and 12% in the UK and Sweden. The researchers comment that

what the respondents understood by a " pain-management specialist " may have

varied from one country to another.

The respondents were visiting their doctor often-60% said they had visited

two to nine times in the past six months for their pain, and 11% had visited

their doctor 10 times in that period. However, they didn't appear to be

getting much satisfaction: 20% felt that their doctor did not see their pain

as a problem, and approximately the same proportion said their doctor never

asked them about their pain. Around 40% of respondents said that they felt

their doctor would rather treat their illness than their pain, and " it must

be emphasized that 28% of respondents with pain believed their doctor does

not know how to control their pain, " the authors write.

" It is striking that patients often do not think that their doctor considers

the pain as a problem, " Breivik and colleagues comment. " While it is clearly

important to treat the patient's underlying condition, it is equally

important to tackle the chronic pain resulting from it. " They note that in

2001, the European Federation of Chapters of the International Association

for the Study of Pain (EFIC) declared that while acute pain may reasonably

be considered a symptom of underlying disease or injury, chronic pain, with

its many consequences for physical activities, socioeconomic burdens, and

quality of life, could be viewed as a disease in its own right.

" Chronic pain should be recognized as an important disease entity, a

healthcare problem in its own right and not only a symptom, and treated with

the same priority as any underlying disease, " say Breivik et al.

Pain scales were rarely used, the researchers note. Across all of Europe,

only 9% of respondents said their doctor had used a pain scale, but the

proportion varied across countries, ranging from 20% in Finland, 15% in the

UK, 14% in France, and 4% in Italy. " Pain scales provide a recognized and

validated method for tracking changes in pain intensity and the

effectiveness of treatments and will signal to the patient that pain is

taken seriously, " the authors comment.

Pain not managed well

Almost half of the pain sufferers were using nonprescription products, while

two thirds were taking prescription medicines for their pain, the survey

found.

The most popular nonprescription products were nonsteroidal

anti-inflammatory drugs (NSAIDs), taken by 55% overall but varying in use by

country, from as high as 91% in Finland and 87% in Austria to as low as 13%

in Denmark and Norway. Products containing acetaminophen (paracetamol) were

taken by 43% overall, but this also varied widely, from 92% in Denmark to 8%

in Germany. Weak opioid analgesics, comprising mostly low doses of codeine

or dihydrocodeine combined with paracetamol or an NSAID, were taken by 40%

of respondents in France, 28% in Ireland, 24% in Poland, 9% in the UK, and

6% in Israel. Most of the other countries don't have these products

available without a prescription, the researchers note.

Of the 3774 patients who had taken prescription medicines, 65% had taken one

or two different products (65%), but more than 10% had taken four or more.

The most common products currently being taken were NSAIDs, taken by 44% of

respondents, followed by weak opioid analgesics (23%), acetaminophen (18%),

and selective COX-2 inhibitors (6%). Overall, 5% of respondents were using

strong opioid analgesics, but this varied widely across the countries-there

was little if any use at all in Italy and Spain, while 11% to 12% were on

strong opioids in the UK and Ireland. The use of weak opioids varied even

more across the different countries, from 50% in the UK and Norway down to

5% to 13% in Israel, Denmark, Italy, and Spain.

When asked how they judged the effectiveness of their current prescription

pain medication, 45% said they were completely or very effective, 41% said

somewhat effective, and 15% said they were not very effective or not

effective at all. Moreover, 64% said there were times when their pain

medicines were not adequate to control their pain, apparently when activity

causes breakthrough pain.

Guidelines for appropriate opioid use needed

In their discussion, the authors comment that the very marked differences in

the use of both nonprescription and prescription forms of the weak and

strong opioid analgesics among the 16 countries clearly indicate that

guidelines for the appropriate use of these drugs in Europe are needed.

" The challenge is to find best practice, a sensible 'middle way' between

opiophobia and opiophilia, with appropriate and responsible use of potent as

well as weak opioid analgesics when the nonopioid analgesics do not suffice

and alternative pain management is not available or fails to help the

patient to a better quality of life, " they say.

Source

1. Breivik H, Collett B, Ventafridda V, et al. Survey of

chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur

J Pain 2005; DOI:10.1016/j.ejpain.2005.06.009.

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