The Problem of Undertreated Pain in Canada'

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The Problem of Undertreated Pain in Canada.

• Toronto Sept 12 2007
• Dr Pam Squire

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Disclosure

• Received honoraria or consultation fees from the
  following companies
• Janssen Ortho, Astra Zeneca, Pfizer,Purdue,Ortho
  Biotech, Bayer, Valeant,Ortho McNeil, Merck
  Frosst, Proctor and Gamble GSK

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Questions

• How prevalent is chronic pain in Canada ?
• 2. How prevalent is the undertreatment of
  chronic pain in Canada?
• 3. What factors are playing a role in the
  undertreatment?
• 4. What is the impact of undertreated pain?

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How prevalent is chronic pain in Canada ?
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Prevalence of Chronic Painin Canada 2001 and
2004 Surveys
2
0
0
1
2
0
0
4
4
5
3
9
4
0
3
3
3
5
3
1
2
9
2
9
3
0
2
7
2
7
2
5
2
5
of respondents
2
5
2
2
2
2
2
0
1
7
1
5
1
0
5
0
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W
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1
8

-

3
4
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5

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5
4
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Defined as continuous or intermittent pain for
at least six months. Moulin DE, et al. Pain Res
Manag 2002 7(4)179-84. Boulanger A, et al. Pain
Res Manag 2007 12(1)39-47.
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Canadian National Pain Study, 2002Condition
Causing The Most Pain (n340)

• Those over 55 years of age are significantly more
  likely to cite arthritis and osteoarthritis
  particularly

Moulin D., PRM, 2002
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Causes of Chronic Disability (US)
The Most Frequent Causes of Disability
Among Americans Aged 18 Years or Older, 1999
CDC.MMWR Morb Mortal Wkly Rep. 200150120-5.
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How prevalent is chronic pain in Canada ?

• It is the single biggest cause of disability for
  Canadians.
• It affects the elderly the most.
• The elderly are about to become the single
  largest cohort of patients we have.

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How prevalent is the undertreatment of chronic
pain in Canada?
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MDs Opinion of Chronic Pain Management in Canada
Base Total sample (n100)
In your opinion how well do you consider moderate
to severe chronic non-cancer pain is managed in
Canada today? Is it?
Moulin D., PRM, 2002
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Canadian National Pain Study What did patients
say.

• Only 36 of patients felt their pain was very
  effectively treated

Moulin D., PRM, 2002
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Canadian Survey of Post-surgical Pain

• 305 Canadian patients surgery in past 3 years
• Both inpatient and day surgery
• Severe or extreme pain 47 inpts 15 outpts
• Still in pain 2 wks afterwards 79 inpts 74
  outpts
• 28 were not getting good pain relief from their
  medications

Rocchi A. Can J Anaesth, 2002
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Is chronic pain in Canada under-treated?

• 64 of patients say it is under-treated.
• 68 of physicians say it is under-treated.

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• What factors are playing a role in the
  undertreatment of chronic pain?

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Issues for Health Professionals

• Lack of knowledge about pain
• Biases and fears about use of opioid analgesics
• Concerns about regulatory scrutiny
• Symptoms are secondary in current
  disease-centered model of care
• Total pain model underutilized
• Bio/psychosocial/spiritual
• Lack of consultation and treatment resources
• Time consuming/poorly remunerated

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Biases and fears about opioid analgesics 2004
data

• Addiction potential - 32
• Cost/coverage - 22
• Abuse/misuse potential - 15
• Over-regulated/paperwork - 15
• BUTA survey of Wisconsin physicians found that
  although concerns about regulatory scrutiny
  ranked low compared to concerns about addiction,
  more than half of the respondents indicated that
  due to concerns about regulatory scrutiny, they
  either reduce drug dose or prescription quantity,
  reduce the number of refills, or choose a less
  potent drug in a lower schedule because of
  concerns about regulatory scrutiny.

Boulanger A, et al. Pain Res Manag 2007
12(1)39-47 Weissman DE, Wisconsin Medical
Journal 199190671-675
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Does regulatory scrutiny reduce opioid
prescribing?

• 1. When a triplicate prescription program was
  introduced in Texas there was a 60.4 reduction
  of schedule 2 drugs in the next year
• 2. A nationwide study of physicians in oncology
  practice showed that "reluctance to prescribe"
  opioids and concern about "excessive regulations"
  was perceived as a barrier to cancer pain
  management, and that these concerns were greater
  among physicians in states with triplicate
  prescription programs.

1.Sigler KA. Am J Hosp Pharm 1984 Jan
(1)108-11 2. Von Roenn J. Proceedings of
American Society of Clinical Oncology
199110326..
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Currently Used Medications for Chronic Pain
Base Total Sample (n340)
Dont know 8
Moulin D., PRM, 2002
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Patient and Family Issues

• Poor pain management is accepted as normal
• Communication problems in a stressed health care
  system
• Lack of availability of pain specialists
• Confusion regarding dependence, tolerance vs.
  addiction to therapeutic opioids
• Fear of adverse effects
• Perception of opioids as a last resort

Boulanger A, et al. Pain Res Manag 2007
12(1)39-47
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What factors are playing a role in the
undertreatment of chronic pain?

• Many factors play a role in the undertreatment of
  pain.
• One powerful factor involves physician and
  patient concern regarding opioid use.
• Making an opioid a triplicate prescription can
  severely reduce its use.
• Governments often concentrate on drug control to
  the exclusion of their obligation to ensure
  opioid availability for medical and scientific
  purposes.

Joranson D.J of Pain Symptom Mgt. 2007
May527-532
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• What is the impact of undertreated pain?

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Consequences of Poor Pain Management- 2004

• Patient suffering - 72
• Economic costs or loss of productivity -37
• Poor quality of life - 30
• Emotional problems or depression - 18
• Need for frequent physician visits - 15
• Does poorly managed chronic pain
• Increase caregiver burden - 85
• Increase physician burden - 80

Boulanger A, et al. Pain Res Manag 2007
12(1)39-47
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The Economic Impact of Pain

• Patients with severe pain who were employed full
  time report missing 7-8 days per year
• 13 of workers lose a mean of 4.6 hrs/week of
  productive work time due to common pain
  conditions
• Costs to industry est. 61.2 billion / year
  (U.S.)
• 76 due to reduced performance at work1
• Cost of depression to industry est 31 billion
  /year (U.S.)

1. Boulanger A.Pain Res Mgt Vol 12 Nol 1 2007 2.
Stewart et al. JAMA 2003 2902443-54. 3. Stewart
et al. JAMA 2003 2893135-44.
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Canadian Chronic Pain Studies 2001 and 2004
Summaries

• Chronic pain
• is a common problem around the world
• increases with age
• has significant medical, social and economic
  consequences to society
• 2/3 of patients and doctors agree that pain is
  poorly managed
• 88 of patients with chronic pain reported
  moderate to severe pain
• Among those with severe pain, 28 were not
  prescribed prescription analgesic (2004)
• Chronic pain remains a major challenge to the
  Canadian healthcare system
• Optimal prescribing of opioids remains negatively
  influenced by physician, regulatory authorities
  and patient concern about addiction, abuse and
  diversion

Moulin DE, et al. Pain Res Manag 2002
7(4)179-84. Boulanger A, et al. Pain Res Manag
2007 12(1)39-47.
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Providing adequate pain management and preventing
diversion and abuse of prescription controlled
substances are both important public health
goals.Achieving both goals requires exchange of
information and perspectives, identification of
issues, and concerted action.Increased
cooperation between regulatory and pain groups
can contribute to a good balance between drug
control and drug availability.
Joranson D. Pain Management and Prescription
Monitoring. Pain and Symptom Management.Vol 23.No
3 2002