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

A huge European survey, involving nearly 50 000 respondents, has shown that one in five adults suffers from chronic pain 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 often60% 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 countriesthere 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: Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain2005; DOI:10.1016/j.ejpain.2005.06.009: Joint and Bone: September 2005 Rheumawire.)