Help and hope at the bottom of the pile

Chronic pain is common—but it isn’t sexy. People who through no fault of their own have their lives demolished by pain deserve our help. The Pain in Europe survey found that 19% of almost 50 000 people questioned in a telephone poll had chronic pain, defined as pain of at least moderate severity occurring almost every day for at least six months.1 One in five of these respondents had pain for more than 20 years, and most had pain for more than five years.

The main causes are back pain and arthritis, and the incidence of chronic pain increases with age. Our populations are ageing. In the United States the number of people aged 65 years or older will have almost doubled by 2025 to 63 million, from 37 million in 2006, and there will be a third of a million Americans over the age of 100 years by 2020.

Chronic pain has a substantial impact on quality of life. A Dutch study that analysed eight large datasets by quality of life factors ranked different medical problems.2 Musculoskeletal conditions (including arthritis and back pain) had the most severe effect on quality of life. This impact of everyday pain on quality of life is something that has yet to be fully appreciated by those who organise our health services and allocate resources.

Most normal or nociceptive pain can be managed with conventional painkillers, from paracetamol through to morphine, with the more powerful painkiller added for more severe pain. Most pains wax and wane, and flexible prescribing takes time to explain. Problematic pains include severe pain on movement with little pain at rest, leaving patients oversedated with painkillers when they are not moving. Problematic side effects of the drugs include drowsiness and constipation, a major burden for elderly people.

Perhaps the most testing pains are those that result from nerve damage, the neuropathic pains. Peripheral nerve damage from surgery, trauma, back pain, and the classic post-herpetic neuralgia, painful diabetic neuropathy, and trigeminal neuralgia often respond poorly to conventional painkillers and need the unconventional drug classes, the antidepressants and the antiepileptics. Titrating these drugs to maximise pain relief and minimise side effects is fiddly but necessary.

Most chronic pain is managed with drugs in primary care. Obstinate pains—pains that resist drug control at acceptable levels of side effects—may need other treatment options, from injections through to a multidisciplinary pain management programme. The necessary skill mix includes nursing, psychology, drug expertise, and injection options and physiotherapy.

The imperative to provide this tier of expertise is humanitarian and economic. Patients with chronic pain who are managed poorly will bounce around the healthcare system, becoming more and more exasperated and consuming considerable resources. Well managed pain contains this excess use of resources, saving an estimated £1500 (€1900; $3000) per patient per year. Set against the background of the large economic burden of chronic pain, the cost of this tier of expertise is marginal.3

An estimate of the financial burden of musculoskeletal illnessin the United States argued for $50bn,4 and the indirect costs of back pain in the United Kingdom are estimated at £11bn.5 Certainly, chronic pain increased costs for payers by more than double, in comparison with matched controls without pain ($C4200 (£2070; €2600; $4100) versus $C1800 a year), an excellent Canadian database survey found.6 There are also financial implications for the person with the pain, reduced household income being the most obvious example.7

No one thing will improve this situation. We need more and better basic research, the most tangible products of which are likely to come from the major drug companies. But there have been pitiably few new painkillers in the past 30 years.

Clinical research and practice are now much more likely to make a difference, helping to make existing evidence sensible and understandable so that people can use it. The evidence base in pain enables us to assess the relative effectiveness of treatments, for instance in nociceptive and neuropathic pain and indeed in migraine. This evidence does not dictate what analgesic to use for a particular patient but does help us to make choices about treatments on the basis of their effectiveness, propensity for harm, and cost.

Then there’s the provision of care. Chronic disease comes low on the political priority list, and chronic pain just gets forgotten. The burden for the sufferers, their families, and society is substantial and merits better treatment. The mark of a gracious society is how it treats those with least voice. That chronic pain puts people at the bottom of the pile is precisely why we should be agitating on their behalf for a fairer share of the medical resource cake.