Cost of Chronic Pain
Today, there is no comprehensive pan-European epidemiologial survey laying out the scope of the pain problem. However, a number of more limited surveys are enough to prove beyond a doubt that pain is a major health problem in Europe. Though all types of pain are important, this summary focuses on chronic pain, which remains one of the most under-recognised, under-treated medical problems of the twentieth century. The statistics demonstrate the tremendous negative impact of chronic pain, highlight the magnitude of the problem, including associated economic costs to society, and identify the seriously reduced quality of life of the millions of chronic pain sufferers. Given the costs associated with chronic pain and the right of sufferers to enjoy a reasonable quality of life, it is imperative that the extent of the chronic pain problem be more widely recognised and addressed.
Definition of Chronic Pain
The International Association for the Study of Pain has defined pain "as an unpleasant sensory or emotional experience resulting from actual or potential tissue damage". Chronic pain may be defined as pain that lasts beyond the usual course of the acute disease or expected time of healing. It may continue indefinitely. Pain that is not relieved despite appropriate treatment is referred to as intractable pain.
Typical Chronic Pain Conditions
|• Osteoarthritis||• Neuropathic pain|
|• Rheumatoid arthritis||• Herpes zoster (shingles) and post-herpetic neuralgia|
|• Low back, shoulder and neck pain||• Trigeminal neuralgia|
|• Headache, including migraine||• Diabetic neuropathy|
|• Cancer pain||• Temporomandibular Joint Disorder (TMJ)|
|• Myofascial pain syndromes||• Postmastectomy pain|
|• Post-thoracotomy pain||• Angina pectoris|
|• Chronic regional pain syndromes||• Chronic visceral pain syndromes|
|• Stump and phantom limb pain|
Incidence and Costs of Chronic Pain
Chronic pain, besides causing untold suffering for millions of patients worldwide, tears at the very economic and social fabric of our culture. To date there are no comprehensive pan-European figures outlining the incidence of the various chronic pain syndromes and their cost to society. However, investigators in various countries have begun to compile information of this nature, which illustrates the magnitude of suffering due to chronic pain. Note that figures vary depending on the definition of pain used, and the specific questions addressed to the people surveyed.
Snapshot of Available Study Results
Data from the cross-sectional national representative Danish Health and Morbidity Surveys (2000, 2005, 2010, and 2013) were combined with The Danish National Prescription Registry at an individual level. The study populations varied between 5000 and 13,000 individuals ≥16 years (response rates: 51-63%). From 2000 to 2013, the prevalence of CNCP increased and subsequently the annual prevalence of opioid use from 4.1% to 5.7% among CNCP individuals. Higher CNCP prevalence was related to female gender, no cohabitation partner, short education, non-Western origin, and overweight/obesity. In addition, women with CNCP, especially >65 years, became more frequent users of opioids and used higher doses than men. Concurrent use of BZD/BZD-related drugs decreased (13%) from 2010 to 2013, still one-third of long-term opioid user were co-medicated with these drugs (Kinge et al 2015).
Data from patients referred to a Danish pain center had a mean pain severity was 7 on a 10 point scale, quality of life measures were severely reduced, 58% had depression or anxiety disorder, 63% had neuropathic pain and 73% of these were taking opiates on referral even though this did not provide adequate pain relief. The study showed that health-related quality of life of chronic non-cancer pain patients is amongst the lowest observed for any medical condition. (Becker et al. 1997).
A prospective longitudinal study of 256 community-dwelling people aged 76 years and older found that chronic pain was reported by 48.9% of the participants at baseline. Persistent chronic pain was associated with poor self-rated health (adjusted odds ratio [AOR]=2.26, 95% confidence interval [95% CI] 1.03-4.98), mobility difficulties (AOR=2.80, 95% CI, 1.22-6.43), and arthrosis or rheumatoid arthritis (AOR=3.07, 95% CI, 1.47-6.42) when compared with persons without chronic pain. However, only 15% of the persons with persistent chronic pain were using analgesics on a regular basis, and one out of every 5 was not taking any analgesics (Karttunen et al 2015).
In Finland from a pool of 5646 patient visits to primary healthcare services, 40% identified pain as the reason for their visit. One-fifth of patients reported having experienced pain for over six months. One quarter of the pain patients of active working age were receiving paid sick leave (Mantyselka et al. 2001).
The direct and indirect economic cost of chronic pain among patients attending a pain management clinic in Ireland was estimated in 100 patients. A per patient of US$24,043 over a 12-month period; more than half was attributable to wage replacementcosts and lost productivity. Hospital stays and outpatient hospital services were the main drivers for health care utilization costs; 63% direct medical costs (Gannon et al 2013)
The economic cost of non-cancer pain was estimated at €5.34 billion or 2.86% of GDP per year (Raftery et al 2012)
In determining the need for a national strategy for pain management in Ireland costs for chronic low back pain were estimated at 28 million representing 33,713 bed days for back pain procedures, 348 million for disability payments, and 1.05million for personal injury claims (Fullen et al 2006)
In an attempt to quantify the total cost of chronic non-cancer pain to the Irish economy in 1995, a study estimated that a sample of 95 patients had already cost the economy £1.9 million at the time of their referral to a multidisciplinary pain clinic (Sheenan et al. 1996).
The findings of a study in the Netherlands indicate that chronic pain is also a common complaint in childhood and adolescence (Perquin et al. 2000).
The total cost of neck pain in the Netherlands in 1996 was estimated to be US $686 million (Borghouts et al. 1999).
Pain is reported in 50% of cancer patients (all stages) and in 75% of patients with advanced neoplasms. Each year more than 100,000 cancer patients experience pain at the time of death in England and Wales (Higginson 1997).
A study in the Netherlands found that musculoskeletal diseases are the fifth most expensive disease category regarding hospital care, and the most expensive regarding work absenteeism and disability (1.7% of GNP) (van Tulder et al. 1995).
In 2012, 18% of men and 27% of women reported musculoskeletal disorders lasting for six months or more in the Survey of Health and Living Conditions. Low back and neck pain were the most common diagnoses both in the general population and as reason for health care utilization. We found that musculoskeletal disorders increased with age, however our results showed no variation in prevalence of chronic disorders between 2002 and 2012 (Kinge et al 2015).
Prevalence of active chronic low back pain (CLBP) in the adult Portuguese population was estimated at 10.4 % (95 % CI 9.6; 11.9 %). After adjustment, active CLBP subjects had a higher likelihood for anxiety symptoms (OR 2.77), early retirement due to disease (OR 1.88) and more physician visits (β = 2.65). Factors significantly and independently associated with the presence of active CLBP were: female gender (OR 1.34), overweight/obesity (OR 1.27), presence of self-reported rheumatic musculoskeletal disease (RMD) (OR 2.93), anxiety symptoms (OR 2.67), age (OR 1.02) and higher number of self-reported comorbidities (OR 1.12) (Gouvela et al 2016).
A cross-sectional nationwide epidemiological study was performed in a random sample of the Portuguese adult population (n=5094). Prevalence of chronic pain CP was 36.7% (95% confidence interval [CI] [35.3-38.2]), based on the definition of the International Association for the Study of Pain. Recurrent or continuous pain was present in 85% of those with CP, and moderate-to-severe intensity and disability were present in 68 and 35%, respectively. Highest CP prevalence was observed among the elderly, retired, unemployed, and less educated. Highest disability was found in relation with family/home responsibilities, recreational activities, occupation/work, and sleep/rest; 13% reported a diagnosis of depression and 49% reported interference in their job. The main factors associated with disability were sex, pain intensity, and depression or depressive symptoms (Azevedo et al 2012)
The prevalence of chronic pain, its characteristics, and its impact on the general Spanish population (n=1,957) was found to be 16.6% (95% confidence interval: 14.9-18.3) and among these subjects, more than 50% referred to limitations in their daily activities, 30% felt sad and/or anxious, and 47.2% indicated that their pain was affecting their family life. Two subgroups of subjects with pain were identified: 1) characterized by generalized pain in more than one location and of a long evolution (150 months); and 2) characterized by pain localized to only one site with a shorter duration (100 months). Individuals who felt anxious because of their pain and those who considered that their pain was affecting their family were more likely to belong to group 1 (Duenas et al 2015).
From a national data base (n=29, 478) from a 2006 study the 1-year prevalence was 19.5% (95% CI: 18.9-20.1) for neck pain and 19.9% (95% CI: 19.3-20.5) for low back pain. Both neck painand low back pain were higher among female (26.4% and 24.5%) than male (12.3% and 15.1%). Subjects in the 31 to 50 years group were 1.5 times (95% CI: 1.3-1.8) more likely to report low back pain than participants in the 16 to 30 years group. Individuals reporting neck or low back painshowed worse self-reported health status (OR: 4.9, 95% CI: 4.5-5.3 for neck pain; OR: 4.7, 95% CI: 4.3-5.1 for low back pain) and were more likely to complain of depression (OR: 4.3, 95% CI: 3.9-4.7 or OR: 3.6, 95% CI: 3.3-3.9, respectively). (Fernández-de-las-Peñas et al 2011)
A postal survey of 10,000 subjects over 65 years aimed to quantify the societal cost of chronic pain, and assess the impact of chronic pain on quality of life. 76.9% were categorized as having no or mild chronic pain, 18.9% as having moderate chronic pain, and 4.2% as having severe chronic pain. Consumed resources increased with the severity of chronic pain. An association between resource use and severity of chronic pain was found; the more severe the chronic pain, the more extensive (and expensive) the use of resources (Bemfort et al 2015).
An epidemiological survey of chronic pain in Sweden found that 45% of all adults have experienced recurrent or persistent pain, 8% severe persistent pain (von Korff et al. 1990).
A postal survey in Sweden found that pain or discomfort, including problems of short duration, were reported by 66% of those questioned, with 40% reporting 'obvious' pain lasting more than 6 months. (Brattberg et al. 1989).
Data from a study in Sweden indicate that spinal pain is very common among 35-45 year old men and woman and that it is related to marked limitations in lifestyle for approximately one fourth of those who experience pain (Linton et al. 1998).
Chronic pain prevalence rates from 19 papers in a systematic review ranged from 35.0% to 51.3% (pooled estimate 43.5%, 95% CIs 38.4% to 48.6%). The prevalence of moderate-severely disabling chronic pain ranged from 10.4% to 14.3%. 12 studies stratified chronic pain prevalence by age group, demonstrating a trend towards increasing prevalence with increasing age from 14.3% in 18-25 years old, to 62% in the over 75 age group, although the prevalence of chronic pain in young people (18-39 years old) may be as high as 30%..Chronic pain was more common in female than male participants (Fayaz et al 2016).
A study of the socio-economic costs of pain syndromes in the UK estimates the direct health care cost of back pain in 1998 to be £1.6 billion. However, this direct cost is insignificant compared to the cost of informal care and the production losses related to it, which total £10.7 billion. Overall, back pain is one of the most costly of all medical conditions (Maniadakis and Gray 2000).
A broadly based epidemiological study of chronic pain in the Grampian region of the UK found that 50% of those surveyed reported chronic pain or discomfort, including 16% with back pain and 16% with arthritis. In 16% of those surveyed chronic pain was severe. (Elliott et al. 1999).
Current yearly costs of back pain and sciatica (alone) in the UK are Euro 9 billion, with Euro1 billion spent each year on direct health case costs (Waddell 1996).
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