| Chronic pain in the Republic of Ireland – Health Research Board funded studies carried out by
Dr. Brian McGuire and colleagues at Centre for Pain Research, NUI Galway.
Studies carried out by Dr Brona Fullen and colleagues in the UCD School of Public Health, Physiotherapy and Population Science
Chronic pain is defined as pain lasting at least 3 months. Chronic pain can vary in intensity and in the extent to which it causes physical disability and psychological distress. Most people with chronic pain will have had pain lasting a number of years before they eventually get access to a specialist pain management service – if they are fortunate enough to have such a service in their area. Because of long waiting times and because multi-disciplinary pain management teams (chartered physiotherapists, clinical psychologists, occupational therapists and pain specialists) are the exception, the people attending pain management programmes tend to have become quite impaired by their pain, making it more difficult to achieve outcomes that will make a discernible difference to the person’s quality of life. The development of a National Pain Management Strategy would enable us to make best use of the limited resources and to treat people earlier in order to reduce long term disability and associated costs. The information provided here is a brief summary of research carried out at NUI Galway which provides the first comprehensive picture of the problem of chronic pain in Ireland.
Study 1 (NUIG)
Chronic pain in the Republic of Ireland community prevalence, psychosocial profile and predictors of pain-related disability: Results from the PRIME study, Part 1. (Published in Pain 2011).
The aims of the study were (1) to determine the prevalence of chronic pain in Ireland (2) to compare the psychological and physical health profiles of those with and without chronic pain. A postal survey of 3136 people was conducted through GP practices with a representative community-based sample of adults. Measures were obtained for sociodemographic variables, physical and psychological well being, depressive symptoms, the presence of pain, pain severity, pain-related disability and illness perceptions. Responses were received from 1204 people. The prevalence of chronic pain was 35.5% and prevalence of pain increased with age and was associated with manual employment. The most commonly reported site of pain was the lower back (47.6%), however, multiple pain sites was the norm with over 80% reporting more than one pain site. Some 12% were unable to work or were on reduced work hours due to pain. Of those with chronic pain, 15% met the criteria for clinically relevant depression compared to 3% of those without pain. The study shows that pain is a prevalent health problem in Ireland and is associated with significant psychological and functional disability.
Study 2 (NUIG)
The economic cost of chronic non-cancer pain in Ireland: Results from the PRIME study, part 2. (Published in Journal of Pain 2012).
To assess the economic cost of chronic pain in Ireland, detailed information was gathered from a sample of 140 people with chronic pain. Direct and indirect costs attributable to chronic pain and medical conditions of which chronic pain was a feature were recorded retrospectively for twelve months. Mean cost per chronic pain patient was estimated at €5,665 per year across all levels of pain severity, with costs increasing according to the severity of pain. A small proportion of patients account for the bulk of costs - the top 5% most expensive patients accounted for 26% of costs, with a mean cost per patient of €29,936 and the 10% most expensive patients were responsible for 43% of all costs. Total cost for individuals aged 20 and above was estimated at €4.76 billion per year, or 2.55% of Irish GDP in 2008. Those with clinically elevated depression scores had costs that were twice as high as people who scored below the depression cut-off score. Chronic pain services in Ireland are generally under-resourced. Improved coordination and better management of patients via interdisciplinary pain rehabilitation programmes is essential and may offer a means of reducing the sizeable economic burden of chronic pain.
Study 3 (NUIG)
Chronic pain persistence, incidence of new pain and predictors of quality of life in a 12-month follow-up of the PRIME study. (In press, Clinical Journal of Pain 2014).
This study examined the persistence of chronic pain and the incidence of new cases of chronic pain in a one-year follow-up study of the sample surveyed for the PRIME study. A postal survey of 1204 people included a battery of pain- and illness-related questionnaires as well as measures of mental health and quality of life. Responses were received from 717 people (60%) who had participated in the first phase of the study. Among those with chronic pain at baseline, 60% still reported chronic pain at one-year follow-up (‘persistent chronic pain’). Persistent chronic pain was associated with a longer history of pain at baseline, more pain sites, higher baseline scores for depression, and greater levels of pain intensity and disability at baseline. At follow-up, 13% who had been free of pain at baseline had developed new chronic pain. Quality of life was greatly reduced in those with persistent pain. Some of the variables that increase risk for long term pain and disability may be modifiable and could thereby reduce the burden of chronic pain.
Study 4 (UCD)
The Need for a national strategy for pain management in Ireland (Published in Irish Journal Medical Science, 2008)
The cost of low back pain (LBP) (common chronic pain condition), the level of education and current chronic pain clinic resources were investigated. The cost of LBP in Ireland is enormous: disability payments from the Department of Social and Family Affairs amounted to €348 million and insurance payments cost €10.5million.The number of teaching hours timetabled for pain education in the schools of Medicine, Physiotherapy, Dentistry, Nursing and Psychology in Ireland’s six universities varied significantly (e.g. 11.5-72 hrs in nursing). No current chronic pain clinics comply with recommended International Association for the Study of Pain (IASP) guidelines. In conclusion a national strategy is needed to reduce costs, standardise teaching and increase pain clinic resources to maximise patient care.
Study 5 (UCD)
Ulysses: The effectiveness of a cognitive behavioural pain management programme – An eight year review (Published in Irish Journal Medical Science 2013)
This study characterised a cohort of patients with chronic pain registered to the Ulysses cognitive behavioural pain management programme (CBT-PMP) in Tallaght Hospital and evaluate the effectiveness of the CBT-PMP 6 months post discharge. In total 553 patients were reviewed. Patients were found to have high levels of psychological morbidity (76 % depression, 84.5 % anxiety), moderate reports of pain [numerical rating scale, mean (SD) 6.0 (2.2)], and low levels of functional activity. At 6 months follow-up, statistically signiﬁcant positive ﬁndings for physical and psychological outcome measures are supplemented by results showing their clinical signiﬁcance. The results support the effectiveness of this model of care, and further resources are required to expand CBT-PMPs nationwide.
Study 6 (NUIG)
Effectiveness of a CBT-based rehabilitation programme (Progressive Goal Attainment Program) for people who are work disabled due to back pain.
Patients (18+) with non-malignant back pain who were work-disabled because of chronic pain were invited to take part in a clinical trial of a psychologically-based pain rehabilitation programme called PGAP. Following screening, 110 patients were randomised to intervention or control condition. Patients allocated to the intervention condition attended up to 10 weekly individual sessions of structured CBT-based active rehabilitation. Patients allocated to the control condition received usual care only. Sessions were delivered by HSE clinical psychologists and focused on graded activity, goal setting, pacing activity and cognitive behavioural techniques to address possible barriers to rehabilitation. Results showed that those in the intervention group had significant reductions in fatigue, depression, fear and avoidance of activity, and negative thinking about pain. Those in the intervention group also had higher rates of return to full-time work after 6 months (20% vs. 12%) and improvement in overall work status (46% vs 25%). The results suggest that this type of rehabilitation programme is beneficial in improving return to work outcomes in patients with back pain. Health economics analysis is underway.
Dr. Brian McGuire is a Clinical Psychologist specializing in pain management. He is Senior Lecturer in Clinical Psychology and Co-Director of Centre for Pain Research at NUI Galway and provides a psychology service at the Pain Clinic, Galway University Hospital.
Dr Brona Fullen is a Chartered Physiotherapist specializing in chronic pain management. She is a Lecturer in the School of Public Health, Physiotherapy and Population Science in University College Dublin