Pain and Ageing

Dr Chris WellsLiverpool

President-Elect, EFIC

Pain Relief Foundation

Liverpool European Capital of culture 2008 BPS 2008

What is EFIC? (European Federation of IASP® Chapters)

The European Federation of IASP® chapters (EFIC®) is a multidisciplinary professional organisation in the field of pain research and medicine, consisting of the 35 European chapters of the International Association for the Study of Pain (IASP®). Established in 1993, EFIC’s constituent chapters represent Pain Societies from thses 35 European countries, and close to 20,000 physicians, basic scientists and researchers,nurses,physiotherapists, psychologists and other healthcare professionals across Europe, who are involved in pain management and pain research.

Can we achieve healthy ageing?An active, independent lifestyle.What prevents it, and can it be managed?

Certainly, the population of Europe is ageing.

+2 HEALTHY LIFE YEARS

A TRIPLE WIN FOR EUROPEEU citizens healthier, more active & independent

until old age

Social & health care systems more sustainable, dynamic & efficient

Competitiveness & market growth of innovations in ageing sector fostered

EIP objectives & target objective by 2020

EU average of HLY at birth

National Health & Wellness Survey

2010 – 65+ Analysis

Langley, 2010

The Big Five

EU (Big 5) Core Therapeutic Report

EU (Big 5) Pain Prevalence 2010 & Age 65+

≠OTC/Herbal Products Caution: †small base size; ††extremely small base size‡Excludes dental problems, headache, menstrual pain or migraine only Questions reference for this slide include: HH10, HH20, PN5, PN15, PN20, PN95, PN120, DB40 (See Appendix)

EU (Big 5)

Total EU (Big 5) Adults & Age 65+

62.0 M (24%)(n=9,963)

Not Experiencing Pain & Age 65+

47.5 M (77%)(n=7,521)

Experiencing Pain (in the past month)‡ &

Age 65+12.3 M (20%)

(n=2,083)

Severe1.8 M (14%)

(n=321)

Moderate8.3 M (68%)

(n=1,349)

Mild2.2 M (18%)

(n=412)

Use Rx1.5 M (86%)

(n=275)

OTC≠ Only100 K (6%)

(n=20††)

Untreated148 K (8%)

(n=26†)

Use Rx5.4 M (64%)

(n=860)

OTC≠ Only1.7 M (20%)

(n=275)

Untreated1.3 M (15%)

(n=214)

Use Rx668 K (30%)

(n=127)

OTC≠ Only863 K (39%)

(n=169)

Untreated677 K (31%)

(n=116)

Total EU (Big 5) Adults & Age 18+

253.7 M (n=57,805)

DATA

SEGMENTATION PROFILES

SAMPLE SIZE

17,10%

24,00%

30,20%

11,40%

17,20%

EXPERIENCING PAIN IN THE PAST MONTH

FRANCE

GERMANY

UK

ITALY

SPAIN

TOTAL ADULT POPULATION: 257.6 MEXPERIENCING PAIN POPULATION: 52.7 M

DEMOGRAPHIC PROFILEAGE

MEAN AGE: 50.9

15

Experiencing Pain (in the past month)‡ & Age 65+

Total Rx Users

Strong Opioids

Weak Opioids NSAIDs COX-2s

AntiConv-ulsants

Amitri-ptyline Analgesics

All Other Pain

Medication7.5 M 661 K 3.7 M 4.1 M 397 K 388 K 46 K 1.2 M 525 K

(n=1,262) (n=125) (n=697) (n=591) (n=54) (n=61) (n=10††) (n=241) (n=68)

Duration of Rx Usage (mean # of months)Experiencing Pain (in the past month)‡ & Age 65+ 81.1 49.2 72.9 78.4 46.8 45.8 56.9 75.3 63.6

Severe 87.0 46.9 85.9 78.5 62.4 55.3 74.7 70.4 65.6Moderate 80.9 52.2 69.4 80.3 44.7 41.3 37.7 76.3 58.4Mild 69.8 24.0 56.2 65.1 27.0 0.0 29.0 84.3 88.4

% Extremely/Very SatisfiedExperiencing Pain (in the past month)‡ & Age 65+ 44% 47% 42% 46% 43% 49% 44% 43% 50%

Severe 38% 46% 40% 30% 27% 32% 32% 52% 57%Moderate 45% 48% 42% 47% 46% 57% 60% 38% 40%Mild 58% 50% 43% 60% 39% - 50% 63% 90%

# Days/Month Report Taking Rx (mean)Experiencing Pain (in the past month)‡ & Age 65+ 18 21 18 14 16 24 25 20 18

Severe 22 23 21 18 22 26 24 21 25Moderate 17 20 17 13 15 24 24 20 17Mild 12 20 13 9 9 0 30 18 10

% Requested Specific RxExperiencing Pain (in the past month)‡ & Age 65+ 35% 25% 28% 38% 27% 30% - 31% 29%

Severe 30% 26% 24% 37% 27% 18% - 32% 26%Moderate 37% 22% 29% 38% 28% 35% - 31% 29%Mild 37% 50% 22% 44% - - - 32% 28%

Pain Prescription Medication Usage

‡Excludes dental problems, headache, menstrual pain or migraine only ††Caution: extremely small base size#Note: mean satisfaction taken into consideration if multiple pain therapies are used.PN35: You indicated you use the following prescription medication(s). Did you request this specific brand from your doctor?.PN40: How many years and/or months have you been using these prescription medication(s)? If you have been using it less than 1 month, please enter a “0” for ”years” and “1” for “months”.PN45: How many days did you use these prescription medication(s) in the past month?PN50: How satisfied are you with these prescription medication(s)?Based on 7 point scale where 1=Extremely dissatisfied and 7=Extremely satisfied In 2010, a "stacked" method was used for determining overall medication satisfaction

Older patients stay on treatment for an average of 81 months, the highest duration is for NSAIDS (6,5 years!)

PAIN CONDITIONSPAIN CONDITION %

BACK PAIN 63

JOINT PAIN 48.0

NECK PAIN 29.6

ARTHRITIS PAIN 21.0

SPRAINS OR STRAINS 8.3

SURGERY OR MEDICAL PROCEDURE PAIN 6.7

FYBROMYALGIA PAIN 5.6

NEUROPATHIC PAIN 4.1

BROKEN BONE PAIN 3.9

CANCER PAIN 0.9

POST HERPETIC NEURALGIA 0.3

17

Co-morbidities

Incidence of co-morbidities is higher in both age groups; however, type of co-morbidity differs – e.g. elderly suffer more from hypertension, high colesterol & diabetes

Total EU (Big 5)

Adults & Age 18+

Total EU(Big 5) Adults

Age Less than 65 Age 65+

Experiencing Pain (in the past month)‡ & Age Less

than 65

Experiencing Pain (in the past month)‡ &

Age 65+

Age Less Than 65

(B) Age 65+

(C)

Not Experien-cing Pain

(D)

Experien-cing Pain

(in the past month)‡

(E)

Not Experien-cing Pain

(F)

Experien-cing Pain

(in the past month)‡

(G)Severe

(H)

Moder-ate(I)

Mild(J)

Severe(K)

Moderate(L)

Mild(M)

253.7 M 191.7 M 62.0 M 140.5 M 38.8 M 47.5 M 12.3 M 6.9 M 22.4 M 9.6 M 1.8 M 8.3 M 2.2 M

(n=57,805) (n=47,842) (n=9,963) (n=34,480) (n=10,237) (n=7,521) (n=2,083) (n=1,970) (n=5,837) (n=2,430) (n=321) (n=1,349) (n=412)^Headache 40% 45%C 22% 38%F 66%DFG 17% 39%F 64% 67%H 67%H 38% 40% 38%^Sleep difficulties 26% 28%C 22% 20%F 50%DFG 16% 39%DF 63%IJ 50%J 41% 52%LM 38% 32%^Heartburn 22% 24%C 18% 19%F 36%DFG 15% 27%DF 39%J 37%J 33% 26% 28% 24%*High blood pressure (Hypertension) 21% 16% 37%B 13% 23%D 33%DE 48%DEF 29%IJ 24%J 19% 56%LM 47% 46%

^Migraine 20% 24%C 10% 20%FG 34%DFG 9% 15%F 38%IJ 35%J 27% 17%M 16%M 10%^Anxiety 20% 23%C 12% 18%F 37%DFG 10% 19%F 47%IJ 37%J 29% 26%LM 19% 14%^Insomnia 17% 18%C 14% 13% 33%DFG 12% 23%DF 47%IJ 33%J 22% 35%LM 22%M 16%*High cholesterol 16% 13% 26%B 11% 19%D 24%DE 35%DEF 22%J 20%J 16% 32% 35% 37%^Abdominal bloating 16% 17%C 12% 13%F 28%DFG 10% 22%DF 31%J 29%J 24% 22% 23%M 17%^Abdominal pain 14% 17%C 7% 12%F 32%DFG 5% 16%DF 34%I 31% 31% 15% 18%M 10%^Depression 13% 15%C 8% 11%F 27%DFG 6% 16%DF 41%IJ 26%J 19% 25%LM 15% 11%*Arthritis 10% 7% 19%B 4% 16%DF 13%D 40%DEF 25%IJ 16%J 9% 50%LM 40% 35%

‡Excludes dental problems, headache, menstrual pain or migraine only *HH5: Which of the following conditions have you ever experienced?^HH10: Which of the following conditions have you experienced in the past twelve months?Letters indicate statistically significant difference @ 95% confidence level between subgroups

Continued…

^Gastroesophageal Reflux Disease (or acid reflux 7% 6% 8%B 5% 11%DF 7%D 12%DF 17%IJ 11%J 7% 18%M 13%M 7%

*Angina 7% 7% 7% 5% 10%DF 6% 12%DEF 8% 10% 10% 17%L 11% 14%

*Diabetes (Type 1 or Type 2) 7% 5% 13%B 4% 7%D 12%DE 15%DEF 11%IJ 6%J 4% 22%LM 15% 12%*Stress Urinary Incontinence (urinary leakage only when coughing, sneezing, laughing or exercising)

6% 5% 9%B 4% 10%DF 8%D 15%DEF 14%IJ 10%J 6% 18% 15% 13%

^Irritable bowel syndrome (with constipation and/or diarrhea)

6% 6% 6% 4% 11%DF 4% 10%DF 17%IJ 12%J 6% 12%M 10% 6%

^Diarrhea (frequent) 5% 6%C 3% 4%F 10%DFG 3% 6%DF 13%IJ 10%J 8% 9%M 6%M 2%

18

Mean Excluding Zero

Mean Including Zero

NotExperienc-ing Pain± (F)

(47.5 M;n=7,521)

ExperiencingPain (in the

pastmonth)‡ (E)

(38.8 M;n=10,237)

NotExperiencing

Pain± (D)

(140.5 M;n=34,480)

Age LessThan 65 (B)

(191.7 M;n=47,842)

Total EU(Big 5)

Adults &Age 18+±

(253.7 M;n=57,805)

0

1

2

3

4+

Total EU(Big 5) Adults

ComorbidityBurden

Zero % implies a very small value less than 0.5% ‡Excludes dental problems, headache, menstrual pain or migraine only±Percentages do not add up to 100% due to roundingCharlson Comorbidity Index Scoring (please see Appendix for details)Letters indicate statistically significant difference @ 95% confidence level between subgroups

Age 65+ (C)

(62.0 M;n=9,963)

Charlson Comorbidity index scores are higher in severe sufferers relative to those with mild/moderate pain, in pain sufferers relative to non-sufferers, and among adults 65+ compared to younger than 65.

ExperiencingPain

(in the pastmonth)‡ (G)

(12.3 M;n=2,083)

Severe± (H)

(6.9 M;n=1,970)

Moderate± (I)

(22.4 M;n=5,837)

Mild (J)

(9.6 M;n=2,430)

Severe (K)

(1.8 M;n=321)

Moderate± (L)

(8.3 M;n=1,349)

Mild± (M)

(2.2 M;n=412)

1.48

0.24

1.42

0.19

1.59J

0.59IJ

1.33

0.23

1.57

0.65

1.40

0.41D

1.47

0.30

1.46

0.46B

1.53DF

0.40D

1.62DF

0.68DEF

1.56J

0.41J

1.75

1.00LM

1.68

0.56

Age Less than 65 Age 65+

Experiencing Pain (in the past month)‡

& Age 65+

Experiencing Pain (in the past

month)‡ & Age Less than 65

C

B

BB

EFG FG

D

DD

G

DE

DD

DEF

DEF

DEFDEF

IJ

IJIJ J

H

J

JJ J

HI

M

M

LML

KKL

COMORBIDITIES

20

Utilization of Healthcare Resources

People with pain use more healthcare resources (~ twice as much); people 65+ having the highest number of visit; but, younger people have more emergency room visits and those with severe pain see their HCP most frequently

Total EU (Big 5)

Adults & Age 18+

Total EU(Big 5) Adults

Age Less than 65 Age 65+

Experiencing Pain (in the past month)‡ & Age Less

than 65

Experiencing Pain (in the past month)‡ &

Age 65+

Age Less Than 65

(B) Age 65+

(C)

Not Experien-cing Pain

(D)

Experien-cing Pain

(in the past month)‡

(E)

Not Experien-cing Pain

(F)

Experien-cing Pain

(in the past month)‡

(G)Severe

(H)

Moder-ate(I)

Mild(J)

Severe(K)

Moderate(L)

Mild(M)

253.7 M 191.7 M 62.0 M 140.5 M 38.8 M 47.5 M 12.3 M 6.9 M 22.4 M 9.6 M 1.8 M 8.3 M 2.2 M

(n=57,805) (n=47,842) (n=9,963) (n=34,480) (n=10,237) (n=7,521) (n=2,083) (n=1,970) (n=5,837) (n=2,430) (n=321) (n=1,349) (n=412)Visited traditional HC provider(s) in past 6 months 85% 82% 93%B 79% 92%D 92%D 97%DEF 97%IJ 93%J 86% 98% 96% 96%

Mean # of visits including zeros 5.5 5.1 6.7B 4.2 8.5DF 5.9D 9.7DEF 13.5IJ 8.4J 5.1 11.9LM 10.0M 7.1

Visited non-traditional HC provider(s) in past 6 months 59% 58% 64%B 53% 73%DF 60%D 76%DEF 77%IJ 74%J 66% 77% 77%M 70%

Visited emergency room in past 6 months 11% 12%C 10% 10%F 17%DFG 9% 15%DF 26%IJ 17%J 12% 25%LM 14% 10%

Hospitalized during past 6 months 8% 7% 10%B 6% 12%DF 8%D 15%DEF 22%IJ 11%J 7% 24%LM 15%M 9%

‡Excludes dental problems, headache, menstrual pain or migraine only TRAD: Which of the following traditional healthcare providers have you seen in the past 6 months?TRADTMI: How many visits did you make to the following traditional healthcare provider(s) in the past 6 months?UTRAD: Which of the following other healthcare providers have you seen in the past 6 months? (Aggregate % shown.)RU5: How many times have you been to the emergency room for your own medical condition in the past six months?RU10: How many times have you been hospitalized for your own medical condition in the past six months?Letters indicate statistically significant difference @ 95% confidence level between subgroups

IMPACT OF PAIN ON HEALTHCARE RESOURCE UTILIZATION

22

Experience Symptoms/Side Effects – Among Rx Opioid Users(Respondents with pain in the past month (qualified respondents), taking opioid medications, experiencing

symptoms)

Constipation

Sleepiness

Dizziness

Nausea

Trouble thinking clearly

Abdominal pain/discomfort

Diarrhea

Other digestive symptoms

Vomiting

Bloating

An exaggerated feeling of happiness, confidence,

or well-being

Feeling moody, irritable,anxious, or restless

Other

None of above

Caution: †small base size; ††extremely small base size ‡Excludes dental problems, headache, menstrual pain or migraine onlyPN60: Please indicate the symptoms you experience while taking <insert name(s) of opioid medication> for your pain?Letter indicates statistically significant difference @ 95% confidence level between subgroups

ExperiencingPain(in the past month)‡ & AgeLess than 65 (E)

(2.4 M; n=684)

Experiencing Pain (in the past

month)* & Age 65+ (G)

(704 K; n=131)Severe (H)

(1.3 M; n=395)Moderate (I)

(993 K; n=272)Mild (J)

(68 K; n=17†)

Experiencing Pain (in the past month)‡ & Age 65+

Experiencing Pain (in the past month)‡ & Age Less than 65

Severe (K)

(341 K; n=66)Moderate (L)

(351 K; n=60)Mild (M)

(13 K; n=5††)

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

I L

G I

G I

G I

E

Incidence of side effects increases with pain severity in both age groups; while older patients report more constipation; younger patients seem to suffer more from CNS side effects

HEALTH STATUS

PAIN POPULATION : MORE PESSIMISTIC

Conclusions Moderate pain; was most common, then mild pain and lastly severe pain.

Nearly all patients either currently use or have used pain medication. However, a greater proportion of those 65+ (69%) currently use a pain medication compared to younger patients (57%). Many experience side effects.

Pain sufferers report greater levels of comorbid conditions relative to non-sufferers.

Pain sufferers tend to utilize healthcare resources at greater levels

The physical & mental health scores and general health levels of pain sufferers relative to non-sufferers are notably lower, correlating with age and severity.

An older sufferer is more likely than a younger sufferer to experience their pain daily.

Incidence of side effects from treatment increases with pain severity.

Multimorbidity in Scotland

The Scottish School of Primary Care’s Multimorbidity Research Programme.

The Slide Pack The Scottish national data shown uses:

– Clinical data from 310 Scottish general practices for 1,754,133 registered patients, and was provided by the Primary Care Clinical Informatics Unit (“PCCIU data”)

– Or clinical data from 40 Scottish general practices linked to hospital admissions data (“ISD and PCCIU data”)

Data on consultations in general practice from a previous study ofover 3,000 patients living in either high or low deprivation areas ofScotland is also referred to, as are examples of experiences from arecent qualitative interview study with people living in some ofthe most deprived areas in Scotland

Please use data & graphs freely with acknowledgementMy thanks also to Ollie Hart, GP, BPS councillor

Multimorbidity in Scotland• Multimorbidity is the presence of two or more long term

conditions. • The Long Term Conditions Alliance Scotland call it ‘having

multiple conditions’. It matters because: • Living with multiple conditions is the norm rather than the

exception for many people. It is associated with poorer quality of life, more hospital admissions and higher mortality

• Health services are largely organised to provide care for single diseases

– The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions

– More people have 2 or more conditions than only have 1– Over 65’s have 50% chance of suffering chronic pain

Multimorbidity is common in Scotland

Most people with any long term condition have multiple conditions in Scotland

“Exhausting”“Demoralising”

“I feel like a wrung-out rag at the end of

consultations”

“If you’re too caring ... you’ll

crack up in a place like this. Our

boundaries lie where they are

because they have to at the moment”

General practitioners and practice nurses in deprived areas struggle to support people with multimorbidity

Chronic Pain

• Occurs in 50% of over 65’s• 3rd most common condition• Often in conjunction with depression (2nd )• Usually as comorbidity• Difficult to treat because ofAccess to careCarer attitudesTreatment conflicts (eg amitriptylene, opioids)Side effect of treatments

Is this what Munch was trying towarn us about?Is that societyin the background,looking the other way?

Conclusions

• The Population is ageing• The EU are looking for healthier ageing• Older people have a huge burden of pain• Pain impairs their quality of life• Older people have multimorbidities• Thus their pain is difficult to treat• We can only succeed in having healthy ageing

if we follow the SIP Road Map

The SIP Road Map for Action 1. acknowledgement of the social

impact of pain

2. timely and adequate access to pain care

3. awareness of the medical, financial and social impact of pain

4. implementation of prevention and education programmes

5. future research and innovation in pain care

6. exchange of best practices

7. monitoring societal outcomes in pain care