Pain and Ageing Dr Chris Wells Liverpool 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 EUROPE EU 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 M (24%) (n=9,963) Not Experiencing Pain & Age M (77%) (n=7,521) Experiencing Pain (in the past month) ‡ & Age M (20%) (n=2,083) Severe 1.8 M (14%) (n=321) Moderate 8.3 M (68%) (n=1,349) Mild 2.2 M (18%) (n=412) Use Rx 1.5 M (86%) (n=275) OTC ≠ Only 100 K (6%) (n=20 †† ) Untreated 148 K (8%) (n=26 † ) Use Rx 5.4 M (64%) (n=860) OTC ≠ Only 1.7 M (20%) (n=275) Untreated 1.3 M (15%) (n=214) Use Rx 668 K (30%) (n=127) OTC ≠ Only 863 K (39%) (n=169) Untreated 677 K (31%) (n=116) Total EU (Big 5) Adults & Age M (n=57,805)

DATA SEGMENTATION PROFILES

SAMPLE SIZE TOTAL ADULT POPULATION: M EXPERIENCING PAIN POPULATION: 52.7 M

DEMOGRAPHIC PROFILE AGE MEAN AGE: 50.9

15 Experiencing Pain (in the past month) ‡ & Age 65+ Total Rx Users Strong Opioids Weak OpioidsNSAIDsCOX-2s AntiConv- ulsants Amitri- ptylineAnalgesics All Other Pain Medication 7.5 M661 K3.7 M4.1 M397 K388 K46 K1.2 M525 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 Severe Moderate Mild % Extremely/Very Satisfied Experiencing Pain (in the past month) ‡ & Age %47%42%46%43%49%44%43%50% Severe 38%46%40%30%27%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 Severe Moderate Mild % Requested Specific Rx Experiencing Pain (in the past month) ‡ & Age %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 CONDITIONS PAIN CONDITION% BACK PAIN63 JOINT PAIN48.0 NECK PAIN29.6 ARTHRITIS PAIN21.0 SPRAINS OR STRAINS8.3 SURGERY OR MEDICAL PROCEDURE PAIN6.7 FYBROMYALGIA PAIN5.6 NEUROPATHIC PAIN4.1 BROKEN BONE PAIN3.9 CANCER PAIN0.9 POST HERPETIC NEURALGIA0.3

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 65Age 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) M191.7 M62.0 M140.5 M38.8 M47.5 M12.3 M6.9 M22.4 M9.6 M1.8 M8.3 M2.2 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 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% 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 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% 5%10% DF 6%12% DEF 8%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% 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 Not Experienc- ing Pain ± (F) (47.5 M; n=7,521) Experiencing Pain (in the past month) ‡ (E) (38.8 M; n=10,237) Not Experiencing Pain ± (D) (140.5 M; n=34,480) Age Less Than 65 (B) (191.7 M; n=47,842) Total EU (Big 5) Adults & Age 18+ ± (253.7 M; n=57,805) Total EU (Big 5) Adults Comorbidity Burden 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 rounding Charlson Comorbidity Index Scoring (please see Appendix for details) Letters indicate statistically significant 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. Experiencing Pain (in the past month) ‡ (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) J 0.59 IJ D B 1.53 DF 0.40 D 1.62 DF 0.68 DEF 1.56 J 0.41 J LM 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 B B EFG FG D D D G DE D D DEF IJ J H J J J J HI M M LM L K KL

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 65Age 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) M191.7 M62.0 M140.5 M38.8 M47.5 M12.3 M6.9 M22.4 M9.6 M1.8 M8.3 M2.2 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 97% DEF 97% IJ 93% J 86%98%96% Mean # of visits including zeros B DF 5.9 D 9.7 DEF 13.5 IJ 8.4 J LM 10.0 M 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 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 only PN60: Please indicate the symptoms you experience while taking for your pain? Letter indicates statistically significant 95% confidence level between subgroups Experiencing Pain(in the past month) ‡ & Age Less 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 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 of over 3,000 patients living in either high or low deprivation areas of Scotland is also referred to, as are examples of experiences from a recent qualitative interview study with people living in some of the most deprived areas in Scotland Please use data & graphs freely with acknowledgement My 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 3 rd most common condition Often in conjunction with depression (2 nd ) Usually as comorbidity Difficult to treat because of Access to care Carer attitudes Treatment conflicts (eg amitriptylene, opioids) Side effect of treatments

Is this what Munch was trying to warn us about? Is that society in 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