Chronic (long-term) pain

Headlines

Chronic pain has the largest negative impact on quality of life of any health condition. The impact of pain on people’s lives can lead to reduced quality of life, depression or sleeplessness. Over 1 in 4 (26%) were affected by chronic pain (either long-term pain or back pain), and 1 in 3 (33%) were affected by any type of pain (short-term or long-term) – the same as in 2008.

Those with long-term pain had the poorest self-rated health, were more likely to suffer from depression (over 1 in 3, 35%), diabetes, high blood pressure, cancer, continence problems and CVD.

Severe pain is estimated at 1 in 10 (11%) among adults¹, whereas in Kirklees 1 in 12 (8%) adults⁹ reported having experienced severe/extreme pain “today”.

Why is this issue important?

Pain continues to be a common condition, affecting most people at some time. It is a complex bio-psychosocial experience¹, usually involving unpleasant sensory and emotional experience associated with actual or potential tissue damage². One of the most frequent types of pain is low back pain and for most people affected, severe pain or disability is short lived. A proportion of people go on to develop chronic pain and disability.

Chronic (long-term) pain is described as:

“pain that persists beyond the point at which healing would be expected to be complete (3-6 months) or that which occurs in disease processes in which healing does not take place”³.

Long-term illness or disease, ongoing conditions, and injuries are the most common causes for chronic pain. Long-term illnesses that may result in chronic pain include cancer, degenerative diseases such as osteoarthritis, osteoporosis, arthritis and multiple sclerosis⁴. Other causes include vascular conditions such as diabetes. Neuropathic pain develops as a result of damage to, or dysfunction of, the system that normally signals pain. Common examples include painful diabetic neuropathy, post-herpetic neuralgia and trigeminal neuralgia⁵.

Chronic pain has the largest negative impact on quality of life of any health condition⁶. The impact of pain on people’s lives is variable but can lead to reduced quality of life, sleeplessness and depression; it interferes with normal physical and social functioning and is associated with job loss^6,7. Approximately 1 in 3 people nationally are affected by chronic pain⁸.

Locally, in 2012⁹:

Nearly 1 in 6 (15%) were affected by long term or chronic pain (not including backache).
1 in 6 (16%) were affected by back pain (sciatica, lumbago or recurring backache).
Over 1 in 4 (26%) were affected by chronic pain (either back pain or any other long-term pain).
1 in 3 (33%) were affected by any type of pain (either short or long-term) – the same as in 2008.

Those with long-term pain had the poorest self-rated health, were more likely to suffer from depression (over 1 in 3 (35%) in comparison to 1 in 5 (21%) in all adults), diabetes, high blood pressure, cancer, continence problems and coronary vascular disease.

1 in 5 (20%) of those with long term pain had three or more long term conditions in comparison to 1 in 7 (14%) of those with back-pain (9% in all adults). Almost 3 out of 4 (71%) people with chronic pain (back pain or any other long-term pain) had regular prescription medication. Over 1 in 3 people with chronic pain regularly bought over the counter medicines for pain relief. Over 1 in 5 (21%) were smokers (compared with 19% of all adults); almost 1 in 4 (24%) were obese (compared with 19% of all adults); and over 1 in 3 (38%) were workless (compared with 26% of all adults of working age).

Severe pain is estimated at 1 in 10 (11%) among adults¹, whereas in Kirklees 1 in 12 (8%) adults⁹ reported having experienced severe/extreme pain “today”. Of these:

2 out of 3 were at least overweight and of these nearly 1 in 3 (29%) of those with severe pain and over 1 in 3 (37%) of those with extreme pain were obese.
4 out of 5 (80%) did not do recommended physical activity levels compared with 2 in 3 (64%) in all adults.
Nearly 1 in 3 (30%) were current smokers compared with 1 in 5 (19%) overall.
1 in 12 (8%) of those with severe pain and 1 in 6 (16%) of those with extreme pain used a wheelchair.
Nearly half (45%) of those with severe pain and 2 in 3 (65%) of those with extreme pain utilised a walking frame.
1 in 4 (25%) indicated that their home was unsuitable to cope with due to physical/ mental health conditions and over 2 in 5 (43%) indicated that their home was unsuitable due to mobility issues.
Those experiencing severe pain were more likely to feel lonely, isolated all/most of the time and were less likely to have someone to count on in a crisis.
Those experiencing severe pain were more likely to have worried about money all/almost all the time in comparison to those with no pain/slight pain.

What significant factors are affecting this issue?

Back pain can be triggered by everyday activities, or it can develop gradually over time as a result of sitting, standing or lifting badly. Risk factors for the development of back pain include being overweight, long-term use of medication that is known to weaken bones, such as corticosteroids, stress and depression¹⁰.

Management of pain

Access to early diagnosis, intervention and better management is key to preventing decline. Pain management benefits from a multidisciplinary approach that includes pharmacologic measures (analgesics, NSAIDs or pain modifiers), interventional procedures, physical therapy and physical exercise, and psychological measures such as cognitive therapy¹¹.

The impact of pain conditions can be improved by adopting positive health behaviours, such as increased activity levels and a healthy diet. Self-care is an integral part of the management of pain. Incorporating self-care approaches within pain management can help people to manage their own condition.

Income and employment

3 in 5 (60%) of those with sciatica were employed, decreasing to less than half (47%) of those with long-term pain. Less than 1 in 3 (30%) of those who rated themselves as having severe pain “today” were employed and only 1 in 10 (10%) of those with “extreme” pain were employed.

Only 1 in 6 (16%) of those with back pain claimed disability allowance and 1 in 10 (9%) claimed incapacity benefit. However 1 in 4 of those with long-term pain claimed disability allowance and this rose to approximately half of those with severe/extreme pain.

Which groups are most affected by this issue?

Nationally, more women (37%) than men (31%) reported chronic pain. Locally over 1 in 4 (27%) men and 1 in 4 (26%) women suffered chronic pain. Of those who reported severe/extreme pain more than half were men, 59%. Of those aged over 65 over 1 in 3 (34%) men and 2 out of 5 (42%) of women had chronic pain.

Age

Chronic pain increased with age from just under 1 in 5 (18%) of those aged 18 – 44 years to almost 1 in 3 (32%) of those aged 45 – 64 years to over 1 in 3 (37%) of those aged 65 and over. Of those who reported severe/extreme pain more were aged 45 – 64 years.

Where is this causing greatest concern?

Experience of long-term pain was similar across the localities (approximately 15%; ranging from 12% in Denby Dale & Kirkburton to 16% in Birstall & Birkenshaw and Dewsbury). For back pain there was more variance, from 13% in Batley to approximately 20% in Birstall & Birkenshaw and Mirfield. Of those reporting severe pain more were from Dewsbury (8%) in comparison to 4% of those in Denby Dale & Kirkburton and Colne Valley.

Views of local people

Those who reported chronic pain (back pain or any other long-term pain) were much more likely to be categorised as Unconfident Fatalists (UF) within the Healthy Foundations Segmentation Profile⁹. 2 out of 5 (40%) of people with chronic pain were from the UF segment (characterised by low levels of self-esteem, control and motivation).
Over 1 in 4 of those with a problem with pain felt that they did not get enough information to help them manage their health in comparison to 1 in 5 of those without pain. Nearly half (46%) of those with moderate pain and half (50%) of those with severe or extreme pain felt that they did not have sufficient information⁹.
Nearly 1 in 3 (31%) of those with pain felt that they did not have enough support from their health and social care team. This increased to 2 in 5 (42%) with severe pain and over half (52%) of those with extreme pain⁹.
Of those with a problem with pain, 1 in 4 were not confident in managing their own health in comparison to 1 in 10 of those with no pain problem. Of those with severe pain nearly half (45%) and nearly 3 in 5 (58%) of those with extreme pain were not confident in managing their condition⁹.

Summarised results from recent qualitative views studies in relation to chronic pain services in Kirklees

Barriers to engagement with chronic pain services

Facilitators to engagement with chronic pain services

· Difficulty accessing GP for appointments.

·           Long waiting time for referral to services,
            pain clinics, physiotherapist, OT
            appointments.

· Badly managed pain medication.

· No follow-up information and advice about
other services available.

· Limited patient information about criteria for
relevant/follow-on/ associated services.

· Different service provision between north
and south Kirklees.

· Need to provide a comprehensive pain
programme rather than one or two sessions.

· Multi-disciplinary assessment with a
requirement to treat the person as a whole.

· More immediate actions for relevant
assessments and investigations.

·           Help with transport to GP services and
            reduction or exemption of prescription
            charges.

· Improved GP understanding of other support
services.

·           More continuity of care “with each service
           having an understanding about other services
           that can provide help”.

· PALS.

· Self-care.

What could commissioners and service planners consider?

Chronic pain continues to present as a long-term health condition that causes extensive and unnecessary suffering and disability. In Kirklees, it is imperative that commissioners and service planners achieve the following patient focused outcomes:

Reduce levels of distress and disability due to long-term pain.
Improve pain symptom control, physical health function and emotional wellbeing.
Improve patients’ confidence to self-manage their pain condition, medication and their health.

Those with back pain could be targeted, assessed and referred to appropriate treatment services at their workplace (as well as at their local GP) as the majority of these individuals are in employment. Workplaces could also take a more prominent role in the prevention of back pain by offering in-house interventions.

Given that the majority of those with chronic pain rated as Unconfident Fatalists according to the Healthy Foundation segmentation profile, specific approaches to behaviour change (related to health behaviours or pain management behaviours) could include face-to-face engagement through trusted channels, offer significant support, tackle mental health issues and utilise a co-ordinated approach to multiple issues, as these are more likely to be successful.

In addition to local evidence, national recommendations should inform our local commissioning plans¹², including:

Development of a strategy to raise public awareness of the ways to prevent chronic pain and improve self-management.
Collaboration between clinicians and people living with pain to assess health needs linked to pain and empower people to improve self-management.
Increase community-based, specialist led services where assessments are made to provide the most effective treatment with the fewest number of steps.

The Kirklees chronic pain pathway and specialist community pain services need to reach the right people, at the right time and place, to reduce the variation in patient experience. The local evidence suggests that current services do not meet people’s needs. Services should be evaluated and GPs/practices nurses/other health professionals offered more training and education on the assessment, referral pathways and services available to those who suffer from this debilitating condition.

References

The British Pain Society. National Pain Audit Final Report; 2012. Available from: http://www.nationalpainaudit.org/media/files/NationalPainAudit-2012.pdf
Merskey H, Bogduk N (eds). Classification of Chronic Pain. International Association for the Study of Pain, Seattle, Part III, Pain Terminology, updated in 2011; 1994.
British Pain Society. Assessment of Pain in Older People; 2007.
Swierzewski. Causes of Chronic Pain; 2011. Available from: http://www.healthcommunities.com/chronic-pain/causes.shtml (accessed on 13th of March 2013).
NICE. Neuropathic Pain: The Pharmacological Management of Neuropathic Pain in Adults in Non-specialist Settings (CG 96); 2010.
Spence D. Bad Medicine: Pain. BMJ; 340: b5683; 2010.
Price C. Putting Pain on the Agenda: The Report of the First English Pain Summit; 2012.
HSE. Chronic Pain. Vol 1. Chapter 9; 2011.
NHS Kirklees and Kirklees Council. Current Living in Kirklees Survey; 2012.
NHS Choices. NHS Help on Offer for People with Pain; 2012. Available from: http://www.nhs.uk/Livewell/Pain/Pages/Longtermpain.aspx
Surgery Door. Pain Management Treatment in the UK; 2010. Available from: http://www.surgerydoor.co.uk/treatments/pain-management/ (accessed on 13^th of March 2013).
Chronic Pain Policy Coalition. Pain Summit Report; 2011.

Date this section was last reviewed

09/07/2013 (PL)