Pain facts and figures to inform policy BLAIR H. SMITH 1. PROFESSOR OF POPULATION HEALTH SCIENCE, UNIVERSITY OF DUNDEE 2. CONSULTANT IN PAIN MEDICINE, NHS TAYSIDE, SCOTLAND 3. NATIONAL LEAD CLINICIAN FOR CHRONIC PAIN, SCOTTISH GOVERNMEN T SIP, 24 TH MAY 2016 1
“One’s knowledge of science begins when he can measure what he is speaking about and express it in numbers”. Lord Kelvin
The magic formula
Components of the formula 1. What is (chronic) pain? 2. Why is it important? a) Prevalence – high and increasing b) Impact on health c) Impact on health services d) Costs to society e) Health inequalities 3. What do we need to do about it?
What is (chronic) pain? Pain: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” Chronic pain : “ Pain that persists beyond normal tissue healing time [3 months ]” International Association for the Study of Pain, 1986
Prevalence. Pain in Europe study Breivik et al 2006 Duration of pain Prevalence of chronic pain among 46,394 adults (>18 years) in 15 European countries and Israel “19% of 46,434 respondents willing to participate had suffered pain for ≥6 months, had experienced pain in the last month and several times during the last week. Their pain intensity was ≥5 on a 10 - point NRS”
“Severe” chronic pain in Scotland 1,150 1,086 Total in Scotland 1,446 267,015 29,119 (NRS mid-2014 population 20,799 estimates) 14,973 18,272 16,111 42,692 57,062 32,414 18,604 5,722 7,561 “Severe” (intense, disabling) chronic pain – 5.6% of adults (Smith et al , 2001)
European Union 28 countries 23 languages 508m citizens... ...in “severe chronic pain”?
Chronic pain prevalence and age Elliott AM et al . Lancet 1999 354 1248-1252 70 60 50 40 Women 30 Men 20 10 0 25-34 35-44 45-54 55-64 65-74 75+ Population prevalence = 46.5%
Chronic pain severity and age Elliott AM et al . Lancet 1999 354 1248-1252 60 50 40 Grade 1 Grade 2 30 Grade 3 Grade 4 20 10 0 35-34 35-44 45-54 55-64 65-74 75+
Scotland 1911 80-84 Age group (years) 70-74 60-64 Males 50-54 40-44 Females 30-34 20-24 10-14 0-4 300 250 200 150 100 50 0 50 100 150 200 250 300 Population in age/sex group (thousands)
Scotland 2031 Age group (years) 80-84 70-74 60-64 50-54 Males 40-44 30-34 Females 20-24 10-14 0-4 300 250 200 150 100 50 0 50 100 150 200 250 300 Population in age/sex group (thousands) Rise and rise of chronic diseases: 60% of adults • Diabetes • Cancer • HIV • Arthritis • CHRONIC PAIN
Components of the formula 1. What is (chronic) pain? 2. Why is it important? a) Prevalence – high and increasing b) Impact on health c) Impact on health services d) Costs to society e) Health inequalities 3. What do we need to do about it?
Global Burden of Disease Study 2013 ◦ CLBP the single greatest cause of disability, by far (146 million YLDs) ◦ MDD 2 nd greatest cause (51 million YLDs) ◦ 4 of the top ten causes of YLDs were chronic pain conditions, globally and in Europe ◦ Other important causes of YLDs are associated with chronic pain (e.g. diabetes, HIV) Lancet 2015
Chronic pain and health 100 90 No chronic 80 pain 70 CPG I 60 50 40 CPG IV 30 20 10 0 Physical Role Pain Energy Role General Social Mental SF-36 Function Physical Emotional Function Health Health Smith BH et al, Family Practice 2001
Chronic pain and mortality Torrance et al 2010 All Circulatory System Deaths All Respiratory System Deaths All cause mortality 1.000 1.00 1.00 CPG 3 groups CPG 3 groups CPG 3 groups 0.998 0.99 No CP No CP No CP Mild Mild Mild 0.95 Severe Severe Severe 0.996 0.98 Cum Survival Cum Survival Cum Survival 0.994 0.90 0.97 0.992 0.96 0.85 0.990 0.95 0.988 0.94 0.80 0 1000 2000 3000 4000 0 1000 2000 3000 4000 0 1000 2000 3000 4000 Follow-up time Follow-up time Follow-up time Adjusted for age, sex and housing tenure
Chronic pain and co-morbidities N = 1.75M Guthrie et al , 2012
Components of the formula 1. What is (chronic) pain? 2. Why is it important? a) Prevalence – high and increasing b) Impact on health c) Impact on health services d) Costs to society e) Health inequalities 3. What do we need to do about it?
Health service impact 4.6 million GP appointments/year for chronic pain in UK (≡793 fulltime GPs) 3 times likelier to be admitted to hospital Greater use of all hospital services (in- and out- patient): “severe” chronic pain>”mild” chronic pain>no chronic pain. Overall and 20/25 clinical specialties, p<0.001 ( χ 2 TREND ) Rising analgesic prescribing costs and adverse effects
Opioid DDDs/million/day 35000 30000 25000 20000 15000 10000 5000 0 N America W Europe Oceania SE Asia Africa 2001-2003 2011-2013 Lancet 2016
Gabapentin prescribing, Scotland 2001-2013 Gross ingredient cost/year (2014/15): Gabapentin £ 6,9M Pregabalin: £ 30.4M
Components of the formula 1. What is (chronic) pain? 2. Why is it important? a) Prevalence – high and increasing b) Impact on health c) Impact on health services d) Costs to society e) Health inequalities 3. What do we need to do about it?
Chronic pain costs society: € 567 billion in healthcare and lost productivity (2010, USA) – 30% more than diabetes and cancer combined € 13.9 billion in lost productivity (1998, UK) € 9.6 billion in lost productivity (2003, Sweden) € 17.4 billion in healthcare for back pain (Germany, 1998) € 168 million in healthcare for back pain (Belgium, 2004) 9.9 million lost working days; 36.5 million reduced working days (2006, Australia) Etc Gaskin and Richard , J Pain , 2012; Phillips, Br J Pain, 2009;
Pain Practice, 2012
Components of the formula 1. What is (chronic) pain? 2. Why is it important? a) Prevalence – high and increasing b) Impact on health c) Impact on health services d) Costs to society e) Health inequalities 3. What do we need to do about it?
Chronic pain is associated with deprivation 45 40 35 30 25 Any chronic pain (%) 20 15 10 5 0 SIMD 1 SIMD 2 SIMD 3 SIMD 4 SIMD 5 Scottish Index of Multiple Deprivation quintiles. 1 = Most deprived
“Severe” chronic pain and deprivation 6 5 4 3 2,7 2,7 2,2 2 1,7 1 1 1 1 0 Multiple logistic regression, adjusted for gender, age, marital status. Smith et al , 2001
SCOTTISH INDEX OF MULTIPLE DEPRIVATION (SIMD) Opioid prescribing, like chronic pain, is closely associated with deprivation SIMD quintiles: 1= most deprived, 5=least deprived STRONG OPIOIDS WEAK OPIOIDS 10.000 35.000 9.000 DDDs per 1,000 population 30.000 DDDs per 1,000 population 8.000 7.000 25.000 6.000 20.000 5.000 15.000 4.000 3.000 10.000 2.000 5.000 1.000 0 0 1 2 3 4 5 1 2 3 4 5 SIMD 2012 SIMD 2012
Opioid DDDs/million/day 35000 30000 25000 20000 15000 10000 5000 0 N America W Europe Oceania SE Asia Africa 2001-2003 2011-2013 Lancet 2016
Components of the formula 1. What is (chronic) pain? 2. Why is it important? a) Prevalence – high and increasing b) Impact on health c) Impact on health services d) Costs to society e) Health inequalities 3. What do we need to do about it?
SIGN Guidelines (2013) “ Management of Chronic Pain ” The first comprehensive, evidence-based guideline internationally Key evidenced recommendations include: ◦ Supported self management ◦ Rational prescribing ◦ Exercise and Physical activity ◦ Appropriate specialist referral Scottish Intercollegiate Guideline Network
Potential benefits of improved management of chronic pain include: For Health service providers: Reduced use of primary care services and acute services Efficient use of specialist services Lower prescribing costs and ADRs Reduced impact of long-term conditions, including co-morbidities Tackling health inequalities For people with chronic pain (particularly older adults) : Increased employment and productivity Better, longer life, with less isolation But we need good data to quantify this
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