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Why pain?


Pain relief has been a major medical interest since Sumerian times 6000 years ago, when poppy juice was first used. Yet there is still a lot of pain about, it is a source of great disability, it detracts from the quality of life, and is often poorly treated. What is needed is more (and perhaps different) research, a concentration on evidence of what works and what does not, and education and dissemination of knowledge to make better use of what we have now.

What is not likely is a magic bullet of a treatment that cures all pain without doing any harm. What we have is actually quite effective. The problem is that, while the best pain relief can be very good indeed, all too often the best is not attained. Reasons are often simple, and have nothing to do with complicated science.

To get the best we need an overview of everything from the best bench science to how best to give the tablets. That is the goal of the the Oxford Pain Relief Trust. The following paragraphs illustrate some of the problems, and suggest some solutions.

Pain, there's a lot of it about

A study carried out in Scotland examined chronic pain in the community [1]. About 5000 questionnaires were sent to people and four out of five replied. The definition of chronic pain used was "pain or discomfort, that persisted continuously or intermittently for longer than three months".

Half of the respondents reported having chronic pain. This increased with age in women and men from about one-third of those aged 25-34 to almost two-thirds in those older than 65 years (Figure 1).

Figure 1: Pain is more common in older people

What pains and when?

The two most common reasons for chronic pain were back pain, which varied little with age, and arthritis, which rose dramatically with age to afflict a quarter of people in their 60s or older. Angina was also more common in older age groups.

And it's not just chronic pain. Large surveys in hospitals show us that about a third of surgical or medical inpatients have pain present all or most of the time, the pain is often severe, and many have to ask for treatments which often take time to arrive [2].

Chronic pain causes real problems

In Scotland the severity of chronic pain was measured and the disability it caused. A quarter of people with chronic pain had pain that was highly disabling and at least moderately limiting. A further quarter had pain that was of high intensity, and all of this despite treatment (Table 1).

Table 1: Pain, its intensity and how it affects daily living

Description of pain and its effects
Percent of people with chronic pain
low disability/low intensity
49
low disability/high intensity
24
high disability/moderately limiting
11
high disability/severely limiting
16

 

Many pain days

Even simple back of envelope calculations demonstrate that the numbert of days someone has pain is large. If even 10% of the population had pain every day (likely from the Scottish survey and others), then there would be over 2 billion days of pain in the UK. That's 30 to 40 days of pain for every one of us!

Impact of pain on quality of life

In Holland research has shed light on how chronic diseases affect quality of life [3]. Eight large data sets were found were analysed by quality of life factors. Ranking different conditions showed that musculoskeletal conditions (including arthritis and back pain), renal disease, cerebrovascular/neurological conditions and gastrointestinal conditions impacted most severely on quality of life.

Figure 2: High scores show greater negative effects on the quality of life

How to make things better

No one thing will accomplish this. We need more and better basic research, the most tangible products of which are likely to come from the major pharmaceutical companies. But experience is that wonderful new and effective treatments are rare beasts.

Clinical research and practice are much more likely to make a difference now, helping to make existing evidence sensible and understandable so that people can use it. An example of this is a league figure of relative effectiveness of treatments for migraine , showing what proportion of people with moderate or severe headache have it more or less relieved by two hours.

Then there's education and dissemination. This is the process of getting the information out to the real world - Grimsby on a wet Tuesday afternoon, rather than the dreaming spires of Oxford on a sunny Summer day. We hope and expect that some of the things we do in research and dissemination will help make that come about.

References:

  1. AM Elliott et al. The epidemiology of chronic pain in the community. Lancet 1999 354: 1248-52.
  2. S Bruster et al. National survey of hospital patients. BMJ 1994 309: 1542-6.
  3. MAG Sprangers et al. Which chronic conditions are associated with a better or poorer quality of life? Journal of Clinical Epidemiology 2000 53: 895-9-7.