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To cite this article: R. M. Leadley, N. Armstrong, Y. C. Lee, A. Allen & J. Kleijnen (2012)
Chronic Diseases in the European Union: The Prevalence and Health Cost Implications
of Chronic Pain, Journal of Pain & Palliative Care Pharmacotherapy, 26:4, 310-325, DOI:
10.3109/15360288.2012.736933
Download by: [Universitat Oberta de Catalunya] Date: 15 December 2017, At: 08:51
Journal of Pain & Palliative Care Pharmacotherapy. 2012;26:310–325.
Copyright © 2012 Informa Healthcare USA, Inc.
ISSN: 1536-0288 print / 1536-0539 online
DOI: 10.3109/15360288.2012.736933
ARTICLE
AB STRACT
The objective of this study was to assess recent data on the prevalence of chronic pain as part of chronic dis-
eases; the prevalence of chronic pain as a chronic condition in its own right; the costs attributed to chronic
pain; and the European Union (EU) policies to addressing chronic pain. Recent literature was reviewed for data
on the prevalence and cost implications of chronic pain in the EU. Following on from an earlier systematic
review, 8 databases were searched for prevalence and 10 for cost information from 2009 to 2011 and rele-
vant EU organizations were contacted. Ten cost and 29 prevalence studies were included from the 142 full
papers screened. The general adult population reported an average chronic pain prevalence of 27%, which
was similar to those for common chronic conditions. Fibromyalgia had the highest unemployment rate (6%;
Rivera et al., Clin Exp Rheumatol. 2009;27[Suppl 56]:S39–S45) claims for incapacity benefit (up to 29.9%;
Sicras-Mainar et al., Arthritis Res Ther. 2009;11:R54), and greatest number of days of absence from work
(Rivera et al., Clin Exp Rheumatol. 2009;27[Suppl 56]:S39–S45). Chronic pain is common and the total pop-
ulation cost is high. Despite its high impact, chronic pain as a condition seems to have had little specific pol-
icy response. However, there does appear to be sufficient evidence to at least make addressing chronic pain
a high priority alongside other chronic diseases as well as to conduct more research, particularly regarding
cost.
KEYWORDS burden, chronic, cost, epidemiology, pain, prevalence
310
R. M. Leadley et al. 311
chronic pain as an issue in the EU reflection process (NHS) Economic Evaluation Database (NHS EED)
on chronic diseases/noncommunicable diseases. were searched from September 2009 to 2011. These
We addressed the following questions: databases were then searched to identify literature on
• What is the prevalence of chronic pain: costs and economic burden of chronic pain, as were
Health Economic Evaluations Database (HEED)
• As part of various chronic diseases? and Cost-Effectiveness Analysis (CEA) Registry (In-
• As a chronic disease in its own right? ternet). An EU countries filter was utilized where
• What is the impact in terms of cost of chronic pain? appropriate. GIN International Guidelines Library,
• Which policies in the EU as a whole and in member NICE Guidance (Internet), National Guidelines
states currently include reference to chronic pain? Clearinghouse (Internet), and INAHTA (Interna-
tional Network of Agencies for Health Technology
Assessment) (Internet) were searched for guidance
from September 2009 to 2011. OpenGrey (Inter-
METHODS net), OAIster (WorldCat), and King’s Fund Library
Database (Internet) were searched from 2005 to 2011
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For question 1a, the population was patients with di- for gray literature. EU Ministries of Health Web sites,
agnoses of chronic diseases including but not limited professional bodies, associations, and societies were
to cancer, diabetes, osteoarthritis, rheumatoid arthri- also searched.
tis, and fibromyalgia. The general adult population The full search strategy can be found in Ap-
was considered for the question 1b. Both the gen- pendix 1.
eral adult population and patients with diagnosis of We also searched EU or country-specific Web sites
chronic diseases were considered for question 2. Only to find gray literature and national and international
moderate to severe chronic pain was included as de- guidelines and guidance. EU health ministries and
fined by the study authors. Studies that concerned pain associations were searched and contacted for rel-
conditions such as migraine, headache, and angina evant material.
pectoris were excluded. For question 3, we looked for This literature review followed the methods and
policies of the EU and within the EU countries. processes recommended in the Centre for Reviews
For question 1, we extracted and summarized data and Dissemination’s (CRD’s) “Systematic reviews:
on prevalence. For question 2, we extracted data on CRD’s guidance for undertaking reviews in health
resource use such as number of physician visits and care.”8 Two reviewers independently inspected the
cost in each country’s currency as well as in euros. abstract of each reference identified by the search
Conversion into euros was carried out using the ex- and determined the potential relevance of each ar-
change rate for the cost year in the study. Resource ticle. For potentially relevant articles, or in cases
use and cost data were from the perspective of health of disagreement, the full article was obtained, inde-
care payers, other public sector, e.g., social care, and pendently inspected, and inclusion criteria applied.
patient (lost work, travel expense) and society (lost Any disagreement was resolved through discussion
productivity). For question 3, we extracted a list of and checked by a third reviewer. Justification for
statements regarding chronic pain, including in par- excluding studies from the review has been docu-
ticular any reference to expenditure and priority. mented. Quality assessment was carried out indepen-
For questions 1 and 2, included study types were dently by two reviewers using a checklist based on
any report of primary research findings, including the STROBE9 document. Any disagreements were
reports of both single studies and reviews (any du- resolved by consensus. For each study, data were ex-
plicates of studies were excluded). For question 3, tracted by one reviewer and checked by a second re-
reports from government and specialist pain agen- viewer. Any disagreements were resolved by consen-
cies were included. The cutoff for recent was the last sus. Data extraction was discussed and decisions doc-
5 years (2006–2011) in order to indicate current pol- umented.
icy. No restrictions on language or publication status
were applied; however, data were only extracted from
publications in English.
Focused searches were undertaken to identify lit- RESULTS
erature on the prevalence of chronic pain. MED-
LINE, Embase, Cochrane Database of Systematic From the references retrieved from the searches, 142
Reviews (CDSR), Database of Abstracts of Re- full text articles were selected and assessed in detail.
views of Effects (DARE), Health Technology Assess- From these, 29 prevalence and 10 cost studies were
ment Database (HTA), and National Health Service identified.
C 2012 Informa Healthcare USA, Inc.
312 Journal of Pain & Palliative Care Pharmacotherapy
Study Characteristics In terms of cost type, only one study reported pri-
vate/patient cost. The most commonly reported type
The majority of prevalence studies were face-to-
was health care (6 out of 10) and then cost of time off
face prospective studies, with some notable excep-
work (4 out of 10). Total public sector cost (including
tions (Tables 1a and 1b). For example, Langley’s
any category but private) was reported in 5 out of 10
2011 study was an Internet-based survey.10 Sauer
studies.
et al. (2011) also carried out their research retrospec-
tively by accessing the German GEK health insurance
records for 2007,11 and Breivik et al. (2009) carried Study Quality
out a telephone survey.12 The majority of the included prevalence studies were
Some single studies provided us with a num- of moderate to high quality, as judged by our quality
ber of results; for example, Fernandez-de-la-Penas assessment tool (Table 4).9 Some moderate-quality
et al. (2011) gave prevalences for both shoulder/neck studies such as Berglund and Nordstrom (2001) and
pain and for lower back pain in the general adult Gerdle et al. (2008) provided no definition or mea-
population.13 Masajtis-Zagajewska et al. (2011) pro- surement of pain and so subjective perception of pain
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vided figures for% prevalence in both the population was reported.22,23 Leijon and colleagues (2009) de-
receiving dialysis and the population having had a scribed low back pain and neck-shoulder-arm pain
kidney transplant,14 whereas Klit et al. (2011) and as pain a couple of days per week or every day.24,25
Neva et al. (2011) both investigated pain in their For our purposes, we have defined low back pain and
chosen population and compared it with a reference neck-shoulder-arm pain as chronic pain.
group.15,16 McGuire et al. (2010) showed some discrepan-
In total, there were 10 cost studies (Tables 2 and cies between number of questionnaire responses and
3). The data collection was in six cases only through number of results recorded.26 Their study also only
questionnaire—face-to-face interview, postal, or self- categorized pain as mild or severe. This inadequate
administered, in two cases medical records facilitated categorization may have resulted in potentially viable
by costing data from reimbursement authorities and results (i.e., moderate pain) being classified as mild
primary care centers, and in two cases mixed methods and therefore not within our inclusion criteria. Walsh
were used. Countries included France, Spain, Ger- et al. (2011) did a similar study using a higher number
many, Denmark, and Sweden and only one of the of participants and categorizing pain as mild, moder-
studies, by Langley, targeted more than one coun- ate, and severe.27 Here the prevalence was 31.1% as
try (United Kingdom, France, Spain, Germany, and compared with 1.3% for McGuire et al. (2010).26,27
Italy).10 The quality of the 10 costing studies was good
Six were related to back pain such as low back (Table 5). However, some failed to provide adequate
pain, neck pain, and spinal pain, the rest covering information for inclusion criteria, characteristics of
fibromyalgia,1 noncancer pain, or any (unspecified) participants, and statistical methods. Depont et al.
chronic pain. Of the 10 studies, 5 provided a defini- (2010), Sicras-Mainar et al. (2009), and Becker et al.
tion of chronic pain. Depont et al. and Sicras-Mainar (2010) were the only three out of the 10 studies that
et al. defined chronic pain as pain lasting at least 3 met all the requirements in the quality assessment
months.17,18 Depont et al. further specified that pain list.2,17,19 In Muller-Schwefe et al. (2011), only source
should occur a minimum of once a week.17 Becker of data and patients’ type of pain were mentioned in
et al. described chronic pain as pain that lasted for the method section, further description of patients’
at least 6 months.19 Muller-Schwefe et al. charac- characteristics or other comorbidities was lacking.20
terized chronic pain as pain that caused more than In Leboeuf-Yde et al. (2011) and Langley (2011),
6 weeks’ sick leave or two prescriptions of opioids the data were collected from cross-sectional question-
within a period of 180 days.20 Rivera et al. defined naires and international survey, respectively, and no
fibromyalgia according to guidance from the Amer- detailed information of participants’ details was pro-
ican College of Rheumatology (1990).1 Where there vided; this was also the case with Kronborg et al.
was no clear definition, studies were included because (2009).10,28,29 In Holmberg and Thelin (2006), the
the term “chronic” was used to describe the pain. The authors only recruited Swedish farmers in the study,
recruited samples in all studies were adult, but the which was the only one out of the 10 studies that
widest age range was greater than 18, the narrowest failed to meet “study population is representative of
being 35–75.1,17 There was only one study, by Holm- target population” in the quality assessment list.21
berg and Thelin (2006) in Sweden, that sampled men Question 1a: What is the prevalence of chronic pain
only; the rest of the studies consisted of both sexes, as part of various chronic diseases? Table 1a shows that
with slightly more female than male.21 chronic pain was reported to be most prevalent in
TABLE 1a. Pain as Part of Chronic Conditions—Prevalence Study Characteristics and Results
Definition of
Study ID Country chronic pain Population Type of pain Study design Sample size Age Prevalence (%)
Note. nr = not recorded; NRS = numeric rating scale (for clinical pain measurement); PPSP = persistent postsurgical pain; RA = rheumatoid arthritis; CP = chronic pain.
313
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314
TABLE 1b. Pain as a Chronic Condition in Its Own Right—Prevalence Study Characteristics and Results
Definition of Prevalence
Study ID Country chronic pain Population Type of pain Study design Sample size Age (%)
Baan 201142 Netherlands 3 months Elderly care Any Face-to-face 957 Mean 77.5 44.0
home
Fernandez-de-la-Penas 2011 (i)13 Spain nr General adult Shoulder/neck Face-to-face 29,478 Over 16 19.5
Fernandez-de-la-Penas 2011 (ii)13 Spain nr General adult Low back pain Face-to-face 29,478 Over 16 19.9
Frieem 200941 Germany 6 months Visiting Any Face-to-face 1201 Mean 53.4 40.0
outpatient
clinics
Gerdle 200823 Sweden 3 months General adult Musculoskeletal Postal 7637 Range 18–74 7.4
Hensler 200939 Germany 3 months General adult Any Face-to-face 1834 3/4 CP over 50 18.4
Horvath 201038 Hungary nr General adult Low back pain Face-to-face 9957 Average 42.1 44.1
Jakobsson 201037 Sweden 3 months General adult Any Postal 826 Average 58.9 46.0
Range
18–102
Klit 2011 (ii)15 Denmark nr General adult Any Postal 519 Median 71 28.9
Langley 201110 Europe 3 months General adult Any Retrospective 53,524 nr 16.6
Leijon 2009 a24 Sweden nr General adult Low back pain Postal 26,611 Mean 43.8 14.2
Leijon 2009 b25 Sweden nr General adult Neck/shoulder/arm Postal 34,707 Mean 43.8 18.0
Neva 2012 (ii)16 Finland 3 months General Adult Back pain Postal 1491 Mean 59 25.0
CP/54 no
CP
Raftery 201140 Ireland 3 months General adult Any Postal 1204 Mean46.8 35.5
TABLE 2. Cost Study Characteristics and Results (Euros Per Person Per Year)
Cost of
Definition of Public sector Health care Social care Private/patient incapacity benefit Cost of time
Study ID Country Type of pain Severity chronic pain cost cost cost cost type payments off work
Becker 201019 Germany Low back pain Any NR 3579.62 1707.62 NA NR NA 1872.00
Depont 201017 France Low back pain Severe 3 months NR 1431.20 NR NR NR NR
Holmberg 200621 Sweden Low back Any NR NA NA NA NA NA NA
pain/neck pain
Kronborg 200929 Denmark Noncancer Any NR NA NA 2021.05∗∗∗ 2064.80∗∗∗ NA NR
Langley 201110 5 EU Any Any NR NA NA NA NA NA NA
countries∗
Leboeuf-Yde 201128 Denmark Spinal pain Any NR NA NA NA NA NA NA
∗∗
Muller-Schwefe 201120 Germany Back pain Any 503.22 NR NR NA NA NR
Rivera 20091 Spain Fibromyalgia Any NR 9982.00 3245.80 NA NA 2266.90 4469.30
Schmidt 200944 Germany Back pain Any NR 2314.98 1095.83 NA NA NA 1219.51
Sicras-Mainar 20092 Spain Fibromyalgia Any 3 months 8654.30 1677.30 NA NA 6161.20 815.80
∗
The UK, France, Spain, Germany, and Italy.
∗∗
More than 6 weeks’ sick leave or two prescriptions of opioids within a period of 180 days.
∗∗∗
Converted to euros by multiplying cost in DKK by 0.1342.
NR = not reported; NA = not applicable; EU = European Union.
315
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316
TABLE 3. Time Off Work Study Characteristics and Results
Incapacity Incapacity
Definition of Days off benefit type benefit type
Study ID Country Type of pain Severity chronic pain Unemployed% work payments (%) definition Study design
Becker 201019 Germany Back pain Any 3 months 4.0 13.6 NA NA Internet-based
Depont 201017 France Low back pain Severe 3 months NA NA NA NA Face-to-face
Holmberg 200621 Sweden Low back Any NR NA NA 4.0 NR Self-administered
pain/neck pain questionnaire
Kronborg 200929 Denmark Low back pain Any NR NA NA NA NA Administrative
Langley 201110 5 EU countries∗ Back pain Any NR 5.1 NR NA NA Postal
Leboeuf-Yde 201128 Denmark Any Any NR NA NA 4.2 Disability Postal
pension
∗∗
Muller-Schwefe 201120 Germany Spinal pain Any NA 2.9 NA NA Administrative
Rivera 20091 Spain Fibromyalgia Any NR 6.0 73 11.9 Permanent Self-administered
working questionnaire and
disability administrative
Schmidt 200944 Germany Noncancer Any NR NA NA NA NA Face-to-face
Sicras-Mainar 20092 Spain Fibromyalgia Any 3 months NA 20.9 29.9 Permanent Telephone, postal,
disability and administrative
pension
∗
The UK, France, Spain, Germany, and Italy.
∗∗
More than 6 weeks sick leave or two prescriptions of opioids within a period of 180 days.
NR = not recorded; NA = not applicable.
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317
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318
TABLE 5. Cost Studies Quality Based on STROBE Checklist
Adequate
description of Adequate description of
Study outcomes (and losses to follow-up (for
Adequate population is how/how often Adequate Adequate longitudinal studies), loss Results reported as
description of Adequate representative measured), description of description of to follow-up less than 10% unadjusted and
study design and description of of target exposures, statistical study at 12 months, or less than confounder-adjusted
Study ID setting eligibility criteria population predictors methods participants 25% for longer follow-up including precision
Becker 201019 Yes Yes Yes Yes Yes Yes Yes Yes
Depont 201017 Yes Yes Yes Yes Yes Yes Yes Yes
Holmberg 200621 Yes No No Yes Yes No Yes Yes
Kronborg 200929 Yes No Yes Yes Yes No Yes Yes
Langley 201110 Yes No Yes Yes Yes No No Yes
Leboeuf-Yde 201128 Yes No Yes No Yes No Yes Yes
Muller-Schwefe Yes No Yes Yes No No Na Yes
201120
Rivera 20091 Yes Yes Yes Yes Yes Yes Na Yes
Schmidt 200944 Yes Yes Yes No Yes Yes Yes Yes
Sicras-Mainar 20092 Yes Yes Yes Yes Yes Yes Yes Yes
60
50
50
40 35
31.1
30
20
9.9
10 6.2
0
Herpes Zoster Cancer Cancer Diabetes Traumac
peripheral injuries
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Giallore 2009 Abbot 2011 Garcia de Paredes Manas 2011 Ciaramitaro 2010
2011
FIGURE 1. Percent prevalence of neuropathic pain as a type of chronic pain in various conditions.
those with Ehlers-Danlos syndrome (EDS), where up pain13,16,24,38 and any specified type of pain being
to 90% of people with EDS suffered from chronic most commonly reported.10,15,37,39–42
pain.22,30 Other chronic conditions in which chronic
pain was reported to be highly prevalent were dia-
betes (35%),31 cancer (9.9–56%),12,32–36 and kidney Chronic Pain Increases With Age
disease, i.e., dialysis and kidney transplant (57% and
51%, respectively).14 Figure 1 shows the prevalence There appears to be a strong link between increasing
of neuropathic pain as part of various conditions and age and prevalence of chronic pain. This is shown in
Figure 2 shows the prevalence of chronic pain in can- the general population and more specifically with re-
cer patients. gard to neck pain,13 lower back pain (LBP), and mus-
Question 1b: What is the prevalence of chronic pain culoskeletal pain.23,38 Fernandez-de-las-Penas et al.
as a chronic disease in its own right? Table 1b shows (2011) shows that the prevalence of neck pain
the prevalence of pain reported as a condition in its increases steadily from 9% in 16–30-year-olds to
own right, i.e., not as a result of any comorbidity. 28.5% in 51–70-year-olds and the prevalence of LBP
Prevalence ranges from 7.4% to 46%23,37 (averaging increases from 9.1% in 16–30-year-olds to 27.4% in
at 27%) in the general adult population, with back 51–70-year-olds.13 Similarly, Horváth et al. (2009)
60
50
40
30
20
10
0
Cancer Head/Neck Breast cancer Cancer Breast cancer Sarcoma Cancer
Cancer
Garcia de Williams Gartner 2009 Manas 2011 Hickey 2011 Kuo 2011 Breivik 2009
Paredes 2011 2010
C 2012 Informa Healthcare USA, Inc.
320 Journal of Pain & Palliative Care Pharmacotherapy
presents data on the age-specific prevalence of LBP to ask for possible relevant policy documents. Lit-
where prevalence of pain increases from 12.5% in tle information that even mentioned chronic pain
14–19-year-olds to 59.1% in 60–65-year-olds.38 Ger- could be found on Web sites and e-mail requests
dle et al. (2008) reports the prevalence of muscu- did not yield additional information either. For ex-
loskeletal pain stratified by age where it increases from ample, in the Major and Chronic Diseases report by
2.4% in under 29-year-olds to 9.1% in >65-year- the European Commission’s Directorate-General for
olds.23 In the population with herpes zoster (HZ), Health and Consumers (DG Sanco), cardiovascular
postherpetic neuralgia (PHN) has the highest preva- disease, diabetes, and mental illness are perceived to
lence in patients aged over 50, with these older pa- be “. . .dominant in mortality and morbidity. . ..”46 We
tients accounting for 90.9% of all cases with PHN (3 also searched the World Health Organization (WHO)
months after HZ diagnosis).43 Web site and found a recent report on chronic dis-
Question 2: What is the impact in terms of cost of eases, “Tackling chronic disease in Europe: Strate-
chronic pain? Cost of health care per patient per year gies, interventions and challenges,”47 which states in
ranged from €1095 in Germany for back pain to the introduction: “This book aims to complement
€3246 for fibromyalgia in Spain.1,44 Social care gen- the two above-mentioned volumes [also on chronic
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erally cost a little less and incapacity benefit payments diseases] by focusing more explicitly on the strate-
were as high as €2267 for fibromyalgia in Spain.1 gies and interventions that policy-makers have at their
Altogether, public sector costs per patient per year disposal to tackle chronic diseases” (p. 2). However,
ranged from €2089 for low back pain in Germany there is no mention of pain at all and one single men-
to €9982 for fibromyalgia in Spain.1,20 tion of musculoskeletal disease; most of the report fo-
Tables 2 and 3 show that fibromyalgia had the cuses on cardiovascular disease (CVD).
highest unemployment rate at 6%,1 highest claim rate Within the European Community Health Indica-
for incapacity benefit (11.9% in one study and 29.9% tors (ECHI) list of indicators published by the Euro-
in another),1,2 and greatest number of days of ab- pean commission towards a sustainable health mon-
sence from work (73 from one study and 20.9 from itoring system in Europe, “general musculoskeletal
another).1,2 It also incurred the greatest costs;, for ex- pain” is mentioned as indicator 37.48 Unfortunately,
ample, public sector cost of €9982 from one study this indicator has not been specified. Furthermore,
and €8654 from another.1,2 chronic pain is not listed on the Public Health Web
Given that most data were available for “back site under either “diseases” or “conditions” and we
type” pain (LBP or back pain), a comparison between could find no routinely collected European Council
countries (Germany and France) was possible, which (EC) or WHO statistics on the prevalence or cost of
showed that health care costs varied little, between chronic pain.49
€1096 in Germany and €1431 in France per person However, there are some promising examples:
per year.17,44 Cost of time off work in back pain was On 15 September 2011, the European Parliament
only available in Germany, at €1219 in one study and adopted a Resolution on the European Union’s po-
€1872 in another study annually.19,44 sition and commitment in advance to the United Na-
Unemployment attributed to pain ranged from 4% tions (UN) high-level meeting on the prevention and
in back pain in Germany to 6% in Fibromyalgia in control of noncommunicable diseases (NCDs). In
Spain.1,19 From the same studies, this coincided with this Resolution, it states: “whereas the majority of
days off work of 13.6 and 73. Percentage receiving in- NCDs have common symptoms, such as chronic pain
capacity type benefit was very similar in most coun- and mental health problems, which directly affect suf-
tries for back type pain at about 4%.21,28 ferers and their quality of life and should be addressed
All costs except that in one study by Kronborg by means of a common, horizontal approach, so that
et al. were in euros.29 Those for the Kronborg et al. health care systems can tackle these diseases more
study were published in Danish krona (DKK) and cost-effectively.”50
converted into euros using the exchange rate for the In the operational plan for the “Strategic Im-
cost year in the study, i.e., 2009.45 plementation Plan of the Pilot European Innova-
Question 3: Which policies in the EU as a whole and tion Partnership on Active and Healthy Ageing”
in member states currently include reference to chronic issued by European Commission, pain is referred
pain? The government Web sites of all 27 European to several times.51 On page 26 of this document,
member states, any international and European pain it states: “Chronic conditions, such as heart failure,
organizations, and the European Commission were respiratory and sleep disorders, diabetes, obesity, de-
searched for documents that mentioned budget al- pression, pain, dementia, and hypertension affect
location for or the priority of chronic pain. Both 80% of people over 65, and often occur simultane-
governments and pain organizations were contacted ously (multimorbidity).”
In some member states, chronic pain has been large part of the population who suffer from chronic
raised as a priority on the agenda treating it as pain conditions” (p. 21).
a disease. Examples are the Netherlands (see re-
port “Chronische pijn” published by the “Regier-
aad Kwaliteit van Zorg”) and Italy (see legge DISCUSSION
038/2010).52,53 The Italian Law 038/2010 is the first
law in Europe that officially recognizes the citizens’ This project has provided recent estimates of the
right to have access to pain therapy, in case of either prevalence of chronic pain within other chronic
cancer or noncancer pain. diseases and as a chronic disease in its own right, and
the cost of chronic pain. What is generally apparent
Stakeholder Responses is the high prevalence and cost of chronic pain. On
average, 80% of patients with EDS reported to suffer
The European Federation of the International Asso- from chronic pain. Of course, EDS is a rare condi-
ciation for the Study of Pain (IASP) Chapters (EFIC) tion, but more common conditions such as diabetes
has been attempting to raise awareness of the impact and cancer reported average prevalences of 35% and
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of chronic pain in order to encourage policy that raises 30%, respectively. In comparison, members of the
its priority in order to better tackle chronic pain. This
is exemplified by the Societal Impact of Pain (SIP), general adult population reported an average chronic
described as “an international platform created in pain prevalence of 27%, which is quite similar to
2010 and aims for those for chronic conditions. Cost per individual
is high. It also appears, at least at the level of the
• raising awareness of the relevance of the impact that European Commission, that chronic pain yet does
pain has on our societies, health and economic sys- not have the adequate priority as evidenced by the
tems lack of mention in policy documents.
• exchanging information and sharing best-practices
across all member states of the European Union In comparison with Reid et al. (2011)7 who con-
• developing and fostering European-wide policy ducted a review of epidemiology of chronic non-
strategies & activities for an improved pain care in cancer pain in Europe, we included cancer pain in
Europe” (http://www.sip-platform.eu). our inclusion criteria as cancer is a common chronic
disease/NCD. Reid et al. found 10 prevalence studies
Although the scientific framework of IASP is un- and 9 cost studies as compared with our 29 preva-
der the responsibility of the European Federation of lence studies and 10 cost studies. Given that we
IASP Chapters (EFIC), the pharmaceutical company searched for publications from 2009 to 2011, this
Grünenthal GmbH is responsible for funding and may indicate an increase in published research and
nonfinancial support (e.g., logistical support). a higher priority for pain. Breivik et al. (2006) inves-
The most recent activity of IASP was to produce tigated chronic pain in Europe: prevalence, impact on
a “Road map for action.”44 It acknowledges the lack daily life, and treatment, and found the average preva-
of priority in the last 10 years since EFIC issued lence of moderate to severe pain to be 19%.56 The lo-
its “Declaration on Chronic Pain as a Disease in cation and cause of pain was also reported. In 2009,
its Own Right”54 and, amongst other things, calls Breivik et al. went on to specifically examine cancer
upon European governments and EU organizations pain in Europe (this 2009 paper is included as part of
to: “. . .acknowledge that pain is an important factor our review).12
limiting the quality of life and should be a top priority Our search strategy has been fully reported,
of the national health care system . . . Strengthen pain is reproducible, and focused on recent studies,
research (basic science, clinical, epidemiological) as which should increase the validity of both cost
a priority in EU framework program and in equiva- and prevalence estimates as an aid to present day
lent research road maps at national and EU level, ad- decision-making. Few data could be obtained from
dressing the societal impact of pain and the burden of the Web and there were few agency responses about
chronic pain on the health, social, and employment government policy. It is hoped, though, that with
sectors.” (p. 1) increasing chronic pain as a priority, such data would
The position that pain requires a higher priority be easier to find.
is also acknowledged in last year’s OPENminds re-
port where it recommends strategies that include the
Study Limitations
following55 : “Make prevention and management of
chronic severe pain and its consequences a health care Although the findings of studies were variable, they
policy priority; allocate adequate resources for organ- were consistent in reporting high prevalence and costs
isation, education and training of qualified personnel of chronic pain. One limitation is the differences
to ensure optimal and adequate level of service to the between studies, which can make them difficult to
C 2012 Informa Healthcare USA, Inc.
322 Journal of Pain & Palliative Care Pharmacotherapy
compare directly. This can be explained by a range of 2. Chronic pain is most prevalent in those patients
factors such as their locations, inclusion of different with other chronic diseases.
populations, design, and definitions used. For exam- 3. Chronic pain can be considered as a very common
ple, the majority of prevalence studies were based and costly chronic disease in its own right.
on data from face-to-face prospective studies, but 4. There is a strong link between increasing age and
some used Internet-based surveys or health insurance prevalence of chronic pain.
records. Age ranges differed as well as the popula- 5. Chronic pain is not adequately prioritized within
tions, such as the general adult population and popu- policies and budgets.
lations with specific underlying diseases; and patients
with any chronic pain or specific chronic pain such a Declaration of interest: The authors report no con-
back pain. Caution must be exercised in comparisons flicts of interest. The authors alone are responsible for
between pain categories and countries given variation the content and writing of the paper.
in reporting and definitions, particularly of incapac-
ity benefit. Indeed, it is a strength to have converted
all monetary costs into euros, but the actual cost esti- REFERENCES
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APPENDIX 1. Search Strategy 16 pain, intractable/ or pain, referred/ (5394)
17 exp Back Pain/ (25320)
18 exp neuralgia/ (10979)
Incidence/Prevalence
19 Neck Pain/ (3489)
Medline (OvidSP) 2009/08–2011/11/wk3 20 exp Arthralgia/ (5828)
21 Fibromyalgia/ (5292)
Date searched: 30.11.11 22 low$ back pain$.mp. (17966)
C 2012 Informa Healthcare USA, Inc.