EPIDEMIOLOGY OF CHRONIC Karla SoareS WeiSer ivan Sola NON-MALIGNANT ed aromatariS JeSúS tornero ConCepCión pérez CéSar margarit PAIN IN SPAIN JoS KleiJnen may 2010 KleiJnen SyStematiC revieWS ltd eSCriCK, yorK, YO19 6Fd, United Kingdom WWW.SyStematiC-revieWS.Com promoted by FUndaCión grünenthal deSign and layoUt by UnderbaU iSbn: 978-84-694-4108-4 © oF the edition and Content: FUndaCión grünenthal The symptom of pain is very frequent in the medical practice. It has been estimated that 34 million adults suffer in the USA from mild to moderate non-malignant pain. Studies made with people over 65 years additionally inform us that 80-85% of them suffer from diseases that are related to pain: 25-50% of them have a moderate pain, amount that increases up to 45-80% for those who live in nursery homes. In Spain, a study made during the year 2000 demonstrated that each Spanish physician attends an average of 181 patients with pain per month, most of them with chronic moderate pain (51.3 persons per month). Table of contents 4 Table of contents 6 List of figures 8 List of tables 11 Introduction to the Epidemiological Review 14 Executive Summary 21 ConClusions 24 Introduction 27 Methods 28 objeCtive of projeCt 28 Questions to be addressed 29 inClusion criteria 31 literature searChes 33 Methods of study selection, quality assessment and data extraction 34 study seleCtion 34 assessment of methodologiCal quality 37 data extraCtion and presentation 39 Results 40 searCh, seleCtion and alloCation of studies 44 Q1 what are the population and demographiCs of Spain? TABLE oF CONTENTS / EPIDEMIOLOGY OF 48 Q2 What is the prevalenCe of chroniC pain conditions in Spain? ChroniC NON-MALIGNANT PAIN IN SPAIN 56 Q3 What is the inCidenCe of chroniC pain conditions in Spain? 57 Q4 What perCentage of chroniC pain patients are (a) untreated and (b) inadeQuately treated 64 Q5 How many chroniC pain patients present themselves for treatment? 69 Q6 How many chroniC pain patients get treated broken down by treatment? 76 Q7&20: What is the complianCe of treated chroniC pain patients and what are the determinants of complianCe / adherenCe to drug treatments? 82 Q8 What are the severity and duration of chroniC pain conditions? 91 Q9 What are the demographiCs of pain sufferers? 97 Q10 What are the underlying diseases of pain sufferers? 102 Q11 How many sufferers have inadeQuate pain control? 107 Q12a What is the impaCt of chroniC pain on quality of life? 113 Q12b What is the impaCt of chroniC pain on aCtivities of daily living? 120 Q12C and d: What is the impaCt of chroniC pain on c. Depression and other mental illness and d. Isolation, helplessness? 132 Q12e&f: What is the impaCt of chroniC pain one) days of work and f) InCapaCity benefits? 140 Q13. What are the costs of chroniC pain from a) SoCietal perspeCtive, b) Health care system perspeCtive and c) Patient perspeCtive? 149 Q14 What are issues/determinants of patients’ awareness of chroniC pain? 157 Q15 what are issues/determinants of health care professionals’ awareness of chroniC pain? 160 Q16. What are the main symptoms and complaints with whiCh patients present themselves to health care professionals? 166 Q17 and Q19: What are the freQuenCies of drug (per WHO class), non-drug, and combined treatments and what are determinants of treatment choiCe within drug treatments? 176 Q18 What are the determinants of treatment choiCe between drug and non-drug treatments? 176 Q21 What is patients’ satisfaCtion about drug treatments? 181 Overallsummary table 195 References List of figures 23 Figure 1: Spain epidemiology flow for moderate to severe chronic pain 40 Figure 2: From Spain, 112 studies were found relevant 41 Figure 3: Epidemiology flow for Spain – number of studies located per question 42 Figure 4: What is the impact of chronic pain – number of studies located per question 42 Figure 5: What are the costs of chronic pain from different perspectives – number of studies located per question 43 Figure 6: Symptoms and awareness – number of studies located per question 43 Figure 7: Treatment – number of studies located per question 44 Figure 8: Age distribution of Spain 2008 45 Figure 9: Weight of the adult Spanish population 2006 46 Figure 10: Percentage of the active population of Spain in employment and unemployed 55 Figure 11: Overview of the prevalence of chronic pain disorders in Spain 67 Figure 12: Proportion of FM patients who had seen a physician for musculoskeletal symptoms in the last year LISt oF FIGURES / EPIDEMIOLOGY OF ChroniC 68 Figure 13: Proportion of non-FM patients who had seen a physician non-MALIGNANT PAIN IN SPAIN for musculoskeletal symptoms in the last year 75 Figure 14: Percentage of pain patients broken down by treatment 81 Figure 15: Determinants of compliance/adherence to therapy 90 Figure 16: Duration in years of chronic pain from the included studies 95 Figure 17: Demographics of patients with chronic pain in included studies 96 Figure 18: Average age of chronic pain patients 101 Figure 19: Comorbidities in the EPISER study 106 Figure 20: Control of pain 118 Figure 21: Functional capacity Collantes-Estevez (2003) 119 Figure 22: Pain interference with job or house work 138 Figure 23: Sick leave due to pain 146 Figure 24: Disability compensations Carmona et al. (2001) 165 Figure 25: Reasons for consultation List of tables 47 Table 1. Population characteristics for Spain 49 Table 2. Characteristics of studies relevant to Question 2: prevalence of chronic pain 53 Table 3. Prevalence data for chronic pain in general, and for different pain disorders 56 Table 4. Characteristics of studies relevant to question 3: incidence of chronic pain 59 Table 5. Characteristics of studies relevant to Question 4a and b: % untreated and % inadequately treated 60 Table 6. Definitions of treated, untreated, inadequately treated and inadequate pain control 61 Table 7. Summary of results for Question 4: % untreated and % inadequately treated 65 Table 8. Characteristics and results of included studies for Question 5: How many chronic pain patients present themselves for treatment 70 Table 9. Study characteristics and results of included studies relevant to Question 6: pain patients broken down by treatment LISt oF TABLES / EPIDEMIOLOGY OF CHRONIC 77 Table 10. Characteristics of two studies relevant to Questions 7 non-MALIGNANT PAIN IN SPAIN and 20: adherence to treatment 84 Table 11. Study characteristics and results for Q8: severity and duration of chronic pain conditions 92 Table 12: Study characteristics and results of studies relevant to Question 9: what are the demographics of pain sufferers? 98 Table 13: Study characteristics of included studies for Q10: underlying diseases of pain sufferers 103 Table 14. Study characteristics of included studies for Q11: how many sufferers have inadequate pain control? 108 Table 15: Characteristics and results of the studies relevant to Question 12: the impact of chronic pain on quality of life 112 Table 16. Results for SF-36 for no pain, pain, acute pain and chronic pain 114 Table 17. Study characteristics and results of included studies for Question 12b: impact on activities of daily living 122 Table 18. Characteristics and results of relevant studies for Q12c&d: impact of pain on depression and other mental illness, isolation and helplessness 128 Table 19. Prevalence of mood disorders in patients with neck and back pain LISt oF TABLES / EPIDEMIOLOGY OF CHRONIC 133 Table 20. Characteristics and results of relevant studies for Q12e&f: non-MALIGNANT PAIN IN SPAIN impact of pain on days off work and incapacity benefits 141 Table 21. Characteristics and results of studies relevant to question 13a, b, c: economic impact of chronic pain 151 Table 22: study characteristics and results of studies relevant to Question 14: issues/determinants of patients’ awareness of chronic pain 158 Table 23: Study characteristics and results of studies relevant to Question 15: issues /determinants of health care professionals’ awareness of chronic pain 162 Table 24: Characteristics and results of studies relevant to Question 16: the main symptoms and complaints with which patients present themselves to health care professionals 168 Table 25. Characteristics and results of studies relevant to Questions 17 and 19: frequency of treatments and determinants of drug treatments 174 Table 26. Percentages of drug type used for different diagnosis for patients newly diagnosed and patients for revision 177 Table 27. Table: Characteristics of the studies relevant to Question 21 182 Table 28. Summary of study quality, results and concluding statements for project questions 2 through 21 Introduction to the Epidemiological Review INTRODUCTION TO THE EPIDEMIOLOGICAL The symptom of pain is very frequent in medical practice. It has been estimated that 34 mil- REVIEW / EPIDEMIOLOGY OF CHRONIC non-MALIGNANT PAIN IN SPAIN lions of adults suffer in the USA from mild to moderate non-malignant pain. Studies made with people over 65 years of age additionally inform us that 80-85% of them suffer from diseases that are related to pain: 25-50% of them have moderate pain, which increases up to 45-80% for those who live in nursery homes. In Spain, a study from the year 2000 demon- strated that each Spanish physician attends an average of 181 patients with pain per month, most of them with chronic moderate pain (51.3 persons per month). Chronic pain has a significant impact on those who suffer it, in the individual, psychologi- cal, familiar and social sphere: anxiety, depression, sleep disorders, frustration, reduction of the libido, reduction of the self-esteem, inactivity and less interest for the social activities, alteration on familiar dynamics, notable implications on the labour sphere with a possible decrease in the level of economic income. Due to this high influence of pain and its health care, its individual and group impact, the present review on the epidemiology of pain is very useful and attractive in the international context, and more specifically for our country.