Pain and Ageing

1. Pain and Ageing Dr Chris Wells Liverpool President-Elect, EFIC

2. Liverpool European Capital of culture 2008 BPS 2008 Pain Relief Foundation

4. Can we achieve healthy ageing? An active, independent lifestyle. What prevents it, and can it be managed? Certainly, the population of Europe is ageing.

7. +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

8. National Health & Wellness Survey 2010 – 65+ Analysis Langley, 2010

9. The Big Five

10. EU (Big 5) CoreTherapeuticReport

11. EU (Big 5) EU (Big 5) Pain Prevalence 2010 & Age 65+ Use Rx1.5 M (86%) (n=275) Severe1.8 M (14%) (n=321) OTC≠ Only100 K (6%) (n=20††) Total EU (Big 5) Adults & Age 18+253.7 M (n=57,805) Untreated148 K (8%) (n=26†) Use Rx5.4 M (64%) (n=860) Experiencing Pain (in the past month)‡ & Age 65+12.3 M (20%) (n=2,083) Moderate8.3 M (68%) (n=1,349) OTC≠ Only1.7 M (20%) (n=275) Total EU (Big 5) Adults & Age 65+62.0 M (24%) (n=9,963) Untreated1.3 M (15%) (n=214) Use Rx668 K (30%) (n=127) Not Experiencing Pain & Age 65+ 47.5 M (77%) (n=7,521) Mild2.2 M (18%) (n=412) OTC≠ Only863 K (39%) (n=169) Untreated677 K (31%) (n=116) ≠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)

12. DATA SEGMENTATION PROFILES

13. SAMPLE SIZE 1:5 (20%) TOTAL ADULT POPULATION: 257.6 M EXPERIENCING PAIN POPULATION: 52.7 M

14. DEMOGRAPHIC PROFILEAGE MEAN AGE: 50.9

15. Older patients stay on treatment for an average of 81 months, the highest duration is for NSAIDS (6,5 years!) 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 15

16. PAIN CONDITIONS

17. 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 Co-morbidities Continued… ‡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 difference @ 95% confidence level between subgroups 17

18. 0 1 2 3 4+ • 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. Total EU(Big 5) Adults Age Less than 65 Experiencing Pain (in the past month)‡ & Age Less than 65 Experiencing Pain (in the past month)‡ & Age 65+ Age 65+ Total EU(Big 5)Adults &Age 18+± (253.7 M; n=57,805) ExperiencingPain (in thepastmonth)‡(E) (38.8 M; n=10,237) ExperiencingPain (in the pastmonth)‡(G) (12.3 M; n=2,083) NotExperiencingPain±(D) (140.5 M; n=34,480) NotExperienc-ing Pain±(F) (47.5 M; n=7,521) Age LessThan 65 (B)(191.7 M; n=47,842) Comorbidity Burden Age 65+ (C) (62.0 M; n=9,963) 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) K KL G H FG EFG HI C M DEF IJ B DE M D J DEF IJ B J LM D D DEF IJ B J L J D D J DEF Mean Excluding Zero 1.47 1.48 1.46 1.42 1.53DF 1.40 1.62DF 1.59J 1.56J 1.33 1.75 1.57 1.68 Mean Including Zero 0.30 0.24 0.46B 0.19 0.40D 0.41D 0.68DEF 0.59IJ 0.41J 0.23 1.00LM 0.65 0.56 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 difference @ 95% confidence level between subgroups 18

19. COMORBIDITIES

20. 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 Utilization of Healthcare Resources ‡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 difference @ 95% confidence level between subgroups 20

21. IMPACT OF PAIN ON HEALTHCARE RESOURCE UTILIZATION

22. 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 Experience Symptoms/Side Effects – Among Rx Opioid Users (Respondents with pain in the past month (qualified respondents), taking opioid medications, experiencing symptoms) Experiencing Pain (in the past month)‡ & Age 65+ ExperiencingPain(in the past month)‡ & AgeLess than 65 (E) (2.4 M;n=684) Experiencing Pain (in the past month)* & Age 65+ (G) (704 K;n=131) Experiencing Pain (in the past month)‡ & Age Less than 65 Severe(H) (1.3 M;n=395) Moderate(I) (993 K;n=272) Mild(J) (68 K;n=17†) Severe(K) (341 K;n=66) Moderate(L) (351 K;n=60) Mild(M) (13 K;n=5††) L I Constipation G I Sleepiness NA Nausea NA Dizziness G I NA Trouble thinking clearly NA Abdominal pain/discomfort G I Feeling moody, irritable,anxious, or restless NA NA Other digestive symptoms NA Bloating NA NA Vomiting NA Diarrhea E An exaggerated feeling of happiness, confidence,or well-being NA NA NA Other None of above NA NA Caution: †small base size; ††extremely small base size ‡Excludes dental problems, headache, menstrual pain or migraine onlyPN60: Please indicate the symptoms you experience while taking <insert name(s) of opioid medication> for your pain?Letter indicates statistically significant difference @ 95% confidence level between subgroups 22

23. HEALTH STATUS PAIN POPULATION : MORE PESSIMISTIC

24. 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.

25. Multimorbidity in Scotland The Scottish School of Primary Care’s Multimorbidity Research Programme.

26. 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

27. 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

28. Multimorbidity is common in Scotland • 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

29. Most people with any long term condition have multiple conditions in Scotland

30. General practitioners and practice nurses in deprived areas struggle to support people with multimorbidity “Demoralising” “Exhausting” “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” “I feel like a wrung-out rag at the end of consultations”

31. Chronic Pain • Occurs in 50% of over 65’s • 3rd most common condition • Often in conjunction with depression (2nd ) • Usually as comorbidity • Difficult to treat because of Access to care Carer attitudes Treatment conflicts (eg amitriptylene, opioids) Side effect of treatments

32. Is this what Munch was trying to warn us about? Is that society in the background, looking the other way?

33. 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

34. The SIP Road Map for Action acknowledgement of the social impact of pain timely and adequate access to pain care awareness of the medical, financial and social impact of pain implementation of prevention and education programmes future research and innovation in pain care exchange of best practices monitoring societal outcomes in pain care