Pain facts and figures to inform policy BLAIR H. SMITH 1. - - PowerPoint PPT Presentation

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

• r 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

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”

Duration of pain

“Severe” chronic pain in Scotland

“Severe” (intense, disabling) chronic pain – 5.6% of adults (Smith et al, 2001)

1,446 42,692 18,272 14,973 20,799 29,119 1,150 16,111 57,062 18,604 7,561 5,722 32,414 1,086

Total in Scotland 267,015

(NRS mid-2014 population estimates)

European Union

28 countries 23 languages 508m citizens... ...in “severe chronic pain”?

Chronic pain prevalence and age

10 20 30 40 50 60 70 25-34 35-44 45-54 55-64 65-74 75+ Women Men Population prevalence = 46.5%

Elliott AM et al. Lancet 1999 354 1248-1252

Chronic pain severity and age

10 20 30 40 50 60 35-34 35-44 45-54 55-64 65-74 75+ Grade 1 Grade 2 Grade 3 Grade 4

Elliott AM et al. Lancet 1999 354 1248-1252

300 250 200 150 100 50 50 100 150 200 250 300

0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Population in age/sex group (thousands) Age group (years)

Scotland 1911

Males Females

300 250 200 150 100 50 50 100 150 200 250 300

0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Population in age/sex group (thousands) Age group (years)

Scotland 2031

Males Females

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 2nd 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

10 20 30 40 50 60 70 80 90 100

Physical Function Role Physical Pain Energy

No chronic pain CPG I CPG IV

Smith BH et al, Family Practice 2001 Social Function Role Emotional Mental Health General Health

SF-36

Follow-up time

4000 3000 2000 1000

Cum Survival

1.00 0.99 0.98 0.97 0.96 0.95 0.94 Severe Mild No CP

CPG 3 groups

All Circulatory System Deaths

Follow-up time

4000 3000 2000 1000

Cum Survival

1.000 0.998 0.996 0.994 0.992 0.990 0.988 Severe Mild No CP

CPG 3 groups

All Respiratory System Deaths

Follow-up time

4000 3000 2000 1000

Cum Survival

1.00 0.95 0.90 0.85 0.80 Severe Mild No CP

CPG 3 groups

All cause mortality

Chronic pain and mortality Torrance et al 2010

Adjusted for age, sex and housing tenure

Chronic pain and co-morbidities

Guthrie et al, 2012

N = 1.75M

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 (χ2

TREND)

• Rising analgesic prescribing costs and adverse effects

5000 10000 15000 20000 25000 30000 35000 N America W Europe Oceania SE Asia Africa

Opioid DDDs/million/day

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

5 10 15 20 25 30 35 40 45 SIMD 1 SIMD 2 SIMD 3 SIMD 4 SIMD 5 Any chronic pain (%) Scottish Index of Multiple Deprivation quintiles. 1 = Most deprived

“Severe” chronic pain and deprivation

1 1,7 1 2,7 1 2,2 2,7 1 2 3 4 5 6 Multiple logistic regression, adjusted for gender, age, marital status. Smith et al, 2001

SIMD quintiles: 1= most deprived, 5=least deprived

SCOTTISH INDEX OF MULTIPLE DEPRIVATION (SIMD)

Opioid prescribing, like chronic pain, is closely associated with deprivation

5.000 10.000 15.000 20.000 25.000 30.000 35.000

1 2 3 4 5

DDDs per 1,000 population SIMD 2012

WEAK OPIOIDS

1.000 2.000 3.000 4.000 5.000 6.000 7.000 8.000 9.000 10.000

1 2 3 4 5

DDDs per 1,000 population SIMD 2012

STRONG OPIOIDS

5000 10000 15000 20000 25000 30000 35000 N America W Europe Oceania SE Asia Africa

Opioid DDDs/million/day

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