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Medical Writer Consultant Pharmacist
Chronic, noncancer pain has received considerably less coverage in the biomedical press than acute postoperative and cancer pain. However, a recent survey has shown that chronic pain affects one in five (19%) adults across Europe and has a profound impact on work and family life. One in four patients believe that their doctors do not know how to control their pain, and 40% of chronic pain patients do not have their pain adequately controlled. This survey, the largest of its kind, has been described as a milestone in our understanding of chronic pain. The findings have important implications for healthcare professionals, especially for pharmacists who are committed to effective pain management.
The survey comprised two phases. In the first phase, computer-assisted telephone interviews (CATIs) were conducted with approximately 3,000 people in each country to determine the prevalence of chronic pain and identify chronic pain sufferers for the second phase. The CATI process used a random dialling method and thereby generated a random sample of the population. In the second phase, 300 chronic pain sufferers in each country were interviewed in depth. Eligible individuals had to be over 18 years of age and have recent history of chronic moderate-to-severe pain.
Prevalence of chronic pain
Overall, chronic pain was found to affect 19% of adults across Europe, but the pattern was not uniform. In Norway, Poland and Italy, the prevalence was 26% or more, whereas in Ireland, the UK and Spain, rates were 13% or lower. Just over one-third of European households had at least one adult pain sufferer (chronic or otherwise).
The average age for chronic pain sufferers is 50 years, and slightly more women than men are affected. Pain sufferers are most likely to live with other people (79%), be married (59%) and have no children living at home (71%). Severe pain sufferers may be somewhat more likely than moderate pain sufferers to be divorced or separated. Thus, a typical chronic pain sufferer in Europe would be a middle-aged, married woman whose children no longer live at home.
Causes, sites and nature of pain
The most common site for pain was the back, with unspecified back pain affecting 24% of all respondents. Lower back pain accounted for a further 18%, and upper back pain for 5%. Other important sites were the knees, legs, head, joints (unspecified), shoulders, neck, hips and hands.
Arthritis or osteoarthritis was the most common cause of pain, accounting for 34% of respondents, followed by herniated or deteriorating discs (15%) and traumatic injury (12%). Less common causes included rheumatoid arthritis, migraine, fracture or deterioration of the spine, nerve damage, cartilage damage, whiplash injury and surgery.
Pain was said to be “constant” or “intermittent” by almost equal numbers of respondents. It was most commonly described as “aching”, with other common descriptors being “annoying”, “intense” and “constant”.
When asked to rate their pain on a 10-point scale, about two-thirds of respondents rated their pain as “moderate” (5–7) and the remainder as “severe” (8–10). The median duration of chronic pain was seven years, but one-fifth of respondents said that they had been in pain for 20 years or more.
Quality of life
A significant number of chronic pain sufferers (44%) worked full- or part-time, but 22% of sufferers were unemployed (excluding those who had retired). Overall, 26% reported that suffering chronic pain had an impact on their jobs, with 19% saying that they had lost a job as a result of their chronic pain. Sixteen percent had changed job responsibilities to accommodate the pain. The mean time off work was 7.8 days in the past six months. Nearly one-third of chronic pain sufferers felt that they were less able to maintain an independent lifestyle as a result of their pain.
Sometimes the pain was so bad that 16% of patients wanted to die and 21% had been diagnosed with depression. Large numbers found that pain prevented them from thinking clearly or concentrating (44%) and made them feel helpless (43%). Half of all respondents felt tired all the time.
One-third of people felt that chronic pain had affected their relationships with family friends and work colleagues. Many felt that their families and colleagues were unsympathetic or unaware of the intensity of their pain, and this left them with feelings of isolation. Social isolation was a particular problem in Denmark, where 50% of sufferers felt unable to discuss their pain with other people.
Almost all respondents felt comfortable discussing pain with their doctors, and 62% were very satisfied with the doctor who was treating their pain. The majority (70%) of consultations were with general or family practitioners; only 23% of respondents had been referred to pain management specialists. A significant proportion (43%) felt their doctors were more focused on their diseases than their pain. Moreover, 28% said that their doctors did not know how to control their pain, and 23% felt that insufficient time was allowed to discuss their pain. Worryingly, 22% said that their doctors never asked about their pain. Satisfaction with doctors was highest in Germany and lowest in Poland (20%) and Israel (39%).
Treatment for chronic pain (prescription medications, over-the-counter [OTC] or alternative treatments) was used by 69% of respondents. At the time of the survey, just over half (52%) of these people were using prescribed treatments, although 78% had tried them at some time. The reasons given for avoiding drug treatment altogether were that people felt they could live with their pain or concerns about side-effects. The majority of those who were currently not using prescription medications did not need them, but concerns about side-effects and lack of effectiveness accounted for 14% and 9%, respectively.
The most commonly used analgesics were nonsteroidal anti-inflammatory drugs (NSAIDs; 45%), followed by weak opioids (24%) and paracetamol (18%). Cyclooxygenase-2 (cox-2) inhibitors and strong opioids accounted for 6% and 5% of usage overall, respectively, and the remainder was made up of barbiturates, ergotamine, antidepressants, disease-modifying antirheumatic drugs (DMARDs)/steroid treatment, antiepileptics, muscle relaxants, and beta-blockers or calcium channel blockers. There was considerable intercountry variations in the patterns of usage. NSAID use was highest in Poland (71%), and Switzerland had the highest use of nonprescription medicines. Opioid use was highest in the UK, where 50% of those taking chronic pain treatment used weak opioids and 12% strong opioids.
About half of the respondents had used nonprescription medicines during the past six months – NSAIDs (56%), paracetamol (42%) and weak opioids (17%).
Only 60% of people had achieved adequate pain control, but in many cases it had taken more than one year to reach this state, and for one-fifth of the sample it took 20 years or more. The lowest levels of satisfactory pain control were found in France and the UK. In contrast, the highest level of satisfaction with prescribed medication was in Germany.
Magazines, newspapers and television were the most widely used sources of information about pain treatments. About one-quarter of respondents received information from their doctors’ surgeries, and only 4% cited pharmacies as a source of information. The internet was used to find information about treatment by 5% of respondents. Overall, one-third said that they felt poorly informed about new methods for managing pain.
This survey has shown that, throughout Europe, chronic pain affects a significant proportion of the adult population and that it has a profound impact on job performance, family life and self-esteem. Moreover, it is undertreated and probably underdiagnosed. In spite of these findings, many chronic pain sufferers have an uncomplaining attitude and appear to accept the status quo. They tend to be passive recipients of information about pain rather than active seekers. Taken together, these findings suggest that there is a need for more and better education of healthcare professionals about chronic pain management, greater awareness of the impact of chronic pain among policymakers and a need for pain services to be provided to match the burden of disease. The European Federation of the International Association for the Study of Pain (IASP) Chapters (EFIC), a large body of experts in pain management (see Resources), has called for pain to be seen as a healthcare problem in its own right. This, it believes, is the most effective way to raise the standard of care for pain patients. Furthermore, this approach to pain fits in with the EU Framework for Public Health, which focuses on horizontal health issues rather than (vertical) disease-specific issues.
Given that 40% of chronic pain sufferers do not have adequate pain control, there is considerable scope for improving the quality of treatment. Clinical pharmacists could have an important role to play in monitoring the outcomes of treatment and in educating patients and prescribers about effective use of analgesics.
The “Pain in Europe” survey was carried out between October 2002 and June 2003 by NFO WorldGroup. The survey was sponsored by Mundipharma International Ltd, Cambridge, UK
EFIC European Federation of IASP Chapters W:www.efic.org
IASP International Association for the Study of Pain W:www.iasp-pain.org
Pain in Europe