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How Does the General Population Treat Their Pain? A Survey in Catalonia, Spain
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Journal of Pain and Symptom Management
Vol. 23 No. 4 April 2002
Original Article
How Does the General Population Treat Their Pain? A Survey in Catalonia, Spain Antònia Bassols, MD, Fèlix Bosch, MD and Josep-Eladi Baños, MD Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Bellaterra, Spain
Abstract Several epidemiological studies have shown that pain is a very common complaint in patients who seek medical care. However, the characteristics of how pain is treated in the general population have been studied less. The present survey was conducted to describe and analyze how the general population of Catalonia (Spain) approaches the treatment of their pain complaints. The study was carried out in 1964 adults who were surveyed by phone about the presence of painful events in the last six months, the intensity and location of their pain, what they did to treat their pain, and their resulting level of relief. Data were compared by age and gender. Pain prevalence was high (78.6%) and more frequent in women. The therapeutic strategy most commonly used was a visit to the physician (66.3%), followed by self-medication (27.6%) and alternative medicines (20.5%). Drugs were the primary treatment used by physicians (86.5%), followed by physical therapy (18.1%). Pain in the extremities, back and neck pain were often unsuccessfully treated. Self-medication was often performed with acetylsalicylic acid and paracetamol (acetaminophen), and was commonly used in conjunction with other therapeutic approaches (51.9%). Age (low use of paracetamol in the elderly) and gender (low use of paracetamol in men) were related to the type of drug used in self-medication. Older men, and those with severe pain located in the chest, required hospital admission more commonly. In conclusion, pain is a common reason for seeking medical care and using drugs. Therapeutic approaches are often related to the type of pain, but also to age or gender. Knowledge of these characteristics may allow for a more efficient use of available resources. J Pain Symptom Manage 2002;23:318–328. © U.S. Cancer Pain Relief Committee, 2002. Key Words General population, pain treatment, pain prevalence, alternative medicines, self-medication
Introduction Pain is a very common complaint in patients who seek the help of health professionals.1 This symptom can severely affect the patients’
Address reprint requests to: Josep-Eladi Baños, MD, Department of Pharmacology, Therapeutics and Toxicology, Faculty of Medicine, Autonomous University of Barcelona 08193, Bellaterra, Spain. Accepted for publication: July 18, 2001 © U.S. Cancer Pain Relief Committee, 2002 Published by Elsevier, New York, New York
quality of life, and it is also becoming a true social disease, as some pains, like low back pain, are becoming highly prevalent. Wall defined pain as the silent epidemic of Western societies.2 Several epidemiological studies have described the main characteristics of pain in the general population.3–11 These surveys report an elevated prevalence of current and chronic pain, as well as a high degree of associated disabilities and limitations. The direct conse0885-3924/02/$–see front matter PII S0885-3924(01)00415-8
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quences for the community are a costly increase of health and social expenditures to cover medical services and disability benefits.12–13 These costs are difficult to quantify precisely and studies are needed to calculate them. One method of evaluating the medical costs of pain in the general population is to investigate how these complaints are treated. Several authors have employed this approach and their results show that pain sufferers visit several health professionals, and use several therapeutic strategies at the same time.3,4,8,14–16 They also use complementary approaches.17,18 However, these studies did not accurately analyze the characteristics of each treatment by the type of pain complaint or the sociodemographic features of patients. This information might help to characterize the different profiles of each population with a specific type of pain, and aid in the development of specific health interventions. An epidemiological study was performed in the general population of Catalonia, a region in northeastern Spain. The first part of the study, which analyzed pain prevalence and characteristics, has been published elsewhere.11 In this paper, we report the second segment of our study, which described and analyzed how people treat their pain.
Methods Setting The study was carried out in Catalonia, a region in the northeast of Spain with an approximate population of 6,000,000. A representative sample of the adult population (18 years of age and older) was chosen at random and divided into age, sex and residential area groups. The figures were taken from the 1991 electoral census, which was made available by the regional statistics center (Institut d’Estadística de Catalunya). Name, age, address and place of residence were listed on the census form. The telephone numbers were obtained by going through the phone books made available by the Spanish phone company (Compañía Telefónica Nacional de España). People excluded from the study were those without a telephone, those who lived in closed institutions (hospitals, prisons, asylums, nursing homes), the homeless, those of no fixed address, and those with mental or physical disabilities which made a telephone
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interview impossible. People were also excluded if we were unable to contact them by phone after 20 attempts in one month.
Sample Size Calculation The size of the sample was obtained by considering a 95% confidence level, a 35% foreseeable pain prevalence, a degree of accuracy of 0.06, and eight groups of stratification (four age intervals by genders). These assumptions gave 243 individuals in each group; thus, the required number for the eight groups was 1944 individuals. Complete data were collected from 1964 individuals. All calculations were based on this final figure. The final sample was taken from a larger sample of 5,000 individuals, which was used to overcome the following limitations: between 10% and 20% of the Catalonian population have no telephone line,19 50% of women are not listed in phone books, and 30% of our initial interviewees were not able to be contacted for various reasons. Each excluded individual was substituted with someone of the same demographic characteristics to achieve the proper distribution. Each group had a predetermined number of individuals established to reflect the actual demographic characteristics of the Catalonian population. Letters were sent and individuals were phoned consecutively as they appeared in the census list of 5,000 individuals until every group was completed. To achieve this goal, a total number of 2,835 letters were sent, but only 2,142 individuals were found. Among them, 1,964 agreed to participate in the survey, resulting in an acceptance rate of 91.7%.
Procedure and Variables Collections of case report forms were carried out via telephone interview. A week before the first phone call, a letter was sent to each possible participant to explain the goals of the study and its characteristics. An initial trial with 100 interviews was undertaken to establish the feasibility of conducting the survey by phone and to sort out any possible difficulties. The main sociodemographic data, pain presence, and the treatment (pharmacological and non-pharmacological) used to treat pain complaints were recorded. All possible variables, along with different categories and subcategories, were later established. The following definitions were used throughout the study.
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Pain prevalence and intensity. Patients were asked if they experienced any pain in the last six months, regardless of its intensity and duration. The presence or absence of pain and its bodily location were determined. When more than one location was reported, the interviewee was asked which had been the most troublesome, and its pain intensity was evaluated by means of a Numerical Scoring Scale (NSS, 1 very mild pain, 10 excruciating pain). All subsequent data obtained related only to this troublesome pain for practical purposes. Pain management strategies. The following therapeutic approaches were considered: visits to a physician (National Health Service or private practice, frequency, type of treatment, drug prescribed), self-medication (drug, degree of improvement), physical therapy, complemen-
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tary therapies, no treatment and/or hospital referral. The degree of improvement with medical treatment was categorized as none, slight, moderate, much or complete. Patients were asked if they tried any management strategy for the pain complaint in the last six months. Sociodemographic data of the sample. Sex, age, place of residence (rural, intermediate or urban sites), civil status, occupational status, social class and level of education were the variables studied (see Bassols et al.11). The categories of sociodemographic variables are shown in Table 1.
Statistical Analysis The survey data were assembled in the software DBASEIII plus and later analysis was carried out using the statistical package SPSS/
Table 1 Sociodemographic Characteristics and Prevalence of Pain
Sample Gender Age (years)
Place of residencea Civil statusb
Educationa
Occupational statusa
Social classa,b
Female Male MeanSD (range) By intervals: 20–30 31–50 51–70 71–91 Rural Intermediate Urban Unmarried Married Widowed Separated/divorced Illiterate Primary (not finished) Primary (finished) Secondary University Employed Unemployed Retired Student Home duties I II III IV V VI
Total (%)
Prevalence (%)
1964 988–50.3 976–49.7 47.517 (20–91)
78.6 85.6 71.5 47.217 [49.718]c
430–21.9 685–34.9 628–32.0 220–11.2 115–5.8 263–13.4 1586–80.8 444–22.7 1307–66.9 150–7.7 52–2.7 83–4.3 305–16.0 802–42.1 411–21.6 305–16.0 1015–52.5 130–6.7 426–22.0 59–3.1 303–15.7 91–4.7 227–11.7 251–13.0 594–30.7 63–3.2 712–36.7
80.5 80.1 77.4 73.6 73.9 75.7 79.4 78.6 78.7 77.3 80.8 86.7 77.7 78.7 77.4 79.7 77.5 76.2 75.1 84.7 86.9 75.8 77.5 77.7 80.3 85.7 77.8
aThe following data were not obtained in all of the interviewees, therefore their n values are smaller than the total sample: civil status (1953); education (1906); occupational status (1933) and social class (1938). bFor details on social class categories, see Bassols et al.11 cIn brackets, mean age and SD for people without pain (n 420).
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PC. Given the exploratory epidemiological nature of the study, the data are presented as descriptive statistics [percentage, mean standard deviation (SD)]. Mean comparisons were calculated with the Student’s t-test and analysis of variance (ANOVA). The 2 test was used for comparing percentages. A 5% significance level was accepted for all tests.
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(36.8%) were the most frequent sites described as painful. Pain prevalence was also related to age, and young people had a higher prevalence than older people.
Characteristics of Pain Management The therapeutic strategy most commonly used was a visit to the physician (66.3%) followed by self-medication (27.6%) and complementary therapies (20.5%). Other treatments commonly used were physical therapy (13.8%) and hospital admission (2.6%). However, 10.6% of all people did not treat themselves at all (Table 2). People often used more than one therapeutic option, with a mean of 1.4. The characteristics of the visit to physician and self-medication are analyzed in the next section. A relationship was observed when comparing sociodemographic data with type of treatment. People who did not follow any treatment were mainly men, young and single. Regarding the characteristics of pain, those of mild or moderate intensity and those affecting the teeth or legs often remained untreated. Middle-aged women more often used complementary therapies, commonly coupled with other treatments (87%). When complemen-
Results Characteristics of the Sample and Pain Prevalence As Table 1 shows, 1964 people were interviewed, of which 50.3% were women; the mean age of the sample was 47.517 years (range 20–91). The majority of participants was from urban areas (80.7%), were married (66.9%), were educated through primary school (42.1%), were employed (52.5%) and belonged to the middle class (31.3% in Group IV). The pain prevalence was high (Table 1), as 78.6% (1453) of the interviewees claimed to have or to have had pain in one or more locations during the 6 months prior to the interview. Women had a higher prevalence (85.6% vs. 71.5% in men) and in more locations (3.4 vs. 2.7). Back (50.9%), head (40.2%) and legs
Table 2 Therapeutic Strategies by Gender and Age Total (%)
Gender(%)
P
Agea Group (%)
P
1023–66.3
F 69.3 M 62.6
0.001
0.001
Self-medication
403–27.6
F 28.2 M 23.6
0.05
Complementary medicine
316–20.5
F 24.9 M 15.2
0.001
Physical therapy
175–13.8
F 12.2 M 10.3
NS
No treatment
163–10.6
F 7.2 M 14.6
0.001
F 1.4 M 4.0
0.01
1–47.8 2–63.4 3–76.1 4–85.8 1–35.1 2–28.6 3–21.4 4–13.0 1–14.2 2–24.0 3–21.4 4–18.5 1–4.9 2–12.2 3–14.6 4–12.3 1–17.1 2–10.9 3–7.0 4–6.2 1–0.9 2–2.0 3–3.7 4–4.9
Visit to the physician
Hospital-based treatment
40–2.6
F female, M male., NS not significant. aAge groups: 1 (20–30); 2 (31–50); 3 (51–70); 4 (70).
0.001
0.01
0.001
0.001
0.05
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tary therapies were chosen, pain was severe and was located in neck, back and abdomen. The most frequent complementary therapies used were herbal teas, massage, focal heat and acupuncture (Tables 2–4). Middle-aged people, both men and women, frequently used physical therapy. The intensity of their pain was high, mainly located in the back, neck, and legs. Physical therapy procedures most commonly used were physical exercise, electrotherapy (ultrasound, short-wave, microwave, laser), superficial heat and massage (Table 2–4). Older men, and those with severe pain in the chest location more commonly needed hospital admission (Table 2–4).
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face (80.0%), legs (82.1%) and back pain (71.9%), as Table 3 shows. Most interviewees went to primary-care centers of the National Health Service (72.6%). Almost a quarter of them (23.3%) also visited private physicians. This behavior was especially important in those with toothaches, and most of these people chose private medical assistance as their first option of treatment (79.1%). Drugs were the most frequently prescribed treatment (86.5%), followed by physical therapy and surgical procedures. A large number of analgesic drugs was used, and their proprietary names frequently were unknown by the interviewees (18.8%). The most frequently reported were simple analgesics (paracetamol [acetaminophen] mainly) and nonsteroidal anti-inflammatory drugs (NSAIDs) (69.7%), followed by a large list which included antibiotics, antacids (almagate was the most frequently prescribed), psychotropic drugs, calcium compounds, and corticosteroid drugs (labeled as “other” in Table 4). The type of analgesic drug that was prescribed related to the pain site (p 0.001). For back, leg or arm pain, the main drugs used were diclofenac, paracetamol and salicylates. Paracetamol, salicylates and propifenazone were pre-
Visit to the Physician As commented earlier, a visit to the physician was the therapeutic option most frequently used. Almost half (44.8%) of the people also chose complementary or physical therapies. Women visited the physician more frequently (p 0.001) and older women did so more than younger ones (p 0.001). Pain was scored as severe (NSS 6.41.9), mainly affecting chest, legs and face. People who visited the physician most often were those affected by chest (88.9%),
Table 3 Pain Characteristics by Therapeutic Strategy
Pain intensitya Specific Strategy Rest of Strategies P Values Pain locationsb Back Head Abdomen Legs Teeth Neck Arms Chest Face P Values
N/n (%) 1000/466 (46.6) 825/367 (44.5) 359/124 (34.6) 724/235 (32.5) 429/104 (24.2) 625/136 (21.8) 531/87 (16.4) 191/18 (9.5) 83/5 (6.0)
Visit to the Physician N 1023
Self Medication N 403
Complementary Medicine N 316
Physical Therapy N 175
No Treatment N 163
Hosp-Based Treatment N 40
6.41.9 (1–10) 5.31.7 (1–10) 0.001
5.81.7 (1–10) 6.12.0 (1–10) 0.01
6.51.9 (2–10) 5.91.9 (1–10) 0.001
6.62.0 (2–10) 5.91.9 (1–10) 0.05
4.81.7 (1–10) 6.21.9 (1–10) 0.001
7.62.2 (3–10) 6.01.9 (1–10) 0.001
71.9 47.4 69.4 82.1 64.4 68.4 62.1 88.9 80.0 0.001
14.6 52.3 21.8 10.2 34.6 22.8 24.1 22.2
24.7 16.1 24.2 20.4 1.9 29.4 16.1 22.2 60.0 0.001
22.9 0.3 0.8 14.5 1.0 14.7 13.8
13.9 5.2 6.5 9.4 16.3 11.0 18.4 5.6
2.8 0.5 6.5 3.8
0.001
0.001
—
0.001
— —
—
—
0.7 1.2 27.8 20.0 0.001
aPain intensity was measured by the numerical scoring scale (1–10) and their values are expressed as mean SD (range). Pain intensity of each specific therapeutic strategy was compared with the reported by patients treated with the other therapeutic strategies. bN: number of people with pain in the last 6 months; n: pain site considered as the most troublesome (in parentheses: percentage of the troublesome pain over all pains at this location). In the columns of therapeutic strategies by pain location, values are expressed as the percentage of people in each pain location who followed every strategy.
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Table 4 Specific Therapeutic Strategies N Visit to the physician
1023
Self-medication
403
Complementary medicine
316
Physical therapy
175
ferred to treat headache. Metamizol, diclofenac and paracetamol were, in this order, the most frequent choices for toothaches, whereas paracetamol, metamizol and piroxicam were used in abdominal pain treatment. There was a large variation in the degree of relief experienced by pain sufferers after treatment and significant differences were observed when pain localization was considered (p 0.001). People reported good pain relief in toothaches, headaches and abdominal pain, whereas pain in the extremities, back and neck pain were often unsuccessfully treated (Fig. 1).
Treatments
N
Percentage
Drug therapy: Paracetamol Diclofenac Salicylates Metamizol Piketoprofen Other (5%) Physical therapy Surgery Other
885 204 188 114 52 41 138 185 69 148
86.5 27.7 25.5 15.4 7.1 5.1 18.7 18.1 6.7 14.5
Acetylsalicylic acid Paracetamol Metamizol Other (3%) Herbal medicines Massage Heat Acupuncture Folk remedies Naturopathy Quack healer Homeopathy Other (5%) Exercise Electrotherapy Heat Massage Other (5%)
198 156 14 22 75 62 58 45 29 24 17 16 69 133 84 33 29 21
44.5 35.1 3.1 17.3 23.7 19.6 18.3 14.2 9.2 7.6 5.4 5.1 21.8 75.1 47.5 18.6 16.4 11.8
In contrast to those taking drugs prescribed by their physicians, most self-medicating people were able to report the proprietary name of the drug which they were taking (96.7%). Pain relief was reported as good by most people who self-medicated (86.6%). The most commonly used drugs were acetylsalicylic acid (ASA) and paracetamol (Table 4).
Self-Medication Self-medication was the choice of 27.6% of the people, and in more than half of them (51.9%), it was used jointly with other therapeutic approaches. Women (p 0.05) and young people (p 0.001) used self-medication most frequently. People who self-medicated reported lower pain levels (NSS 5.81.7) than those who did not (NSS 6.1 2.0, p 0.01). This behavior was more common in headaches (52.3%) and toothaches (34.6%) sufferers (Table 3).
Fig. 1. Pain relief after medical treatment by pain location. In parentheses, number of interviewees who reported the level of their pain relief after visiting their physician.
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Further analysis was conducted to consider the differences of use of each analgesic drug by age and gender (Figs. 2 and 3). The use of ASA increased in accordance with person’s age, whereas paracetamol followed an inverse pattern. When gender was considered, women used ASA (48.8%) and paracetamol (39.2%) similarly. However, men reported a clear preference for ASA (60.8%) over paracetamol (21.5%).
Discussion The main goal of our study is to analyze how the general population copes with their pain complaints in their everyday life. Few studies have been devoted to this topic and, in general, attention has been centered on chronic pain patients at pain centers21 or in primary health care.16 But chronic pain is only a small part of all pain complaints. In fact, many people with acute ailments do not seek medical care and self-treat with drugs or other nonpharmacological therapies. For instance, few women with menstrual pain will ask for advice every month and instead use known remedies to get relief. The same would probably be true for many sufferers of headaches, including migraine. The main consequence of such a situation is that the presence of pain might be overlooked in many people, as acute pain and chronic pain not considered as such (e.g., menstrual pain or migraine) are under-represented. Our survey has tried to avoid this limi-
Fig. 2. Drugs used in self-medication according to the age of interviewees. Other drugs included metamizol, diclofenac and a large number of NSAIDs and analgesic drugs. ASA Acetylsalicylic acid.
Fig. 3. Drugs used in self-medication by gender. In parentheses, number of interviewees who self-medicated with each drug. ASA Acetylsalicylic acid.
tation by asking all people if any pain complaint was present and how they treated it. Some characteristics of our study are different from other surveys on pain prevalence. Although data on pain complaints in any location were obtained,11 information on pain treatment was only obtained for the most troublesome pain. The reason for this choice was the need to shorten the phone interview and to avoid the unreliability of data if this was too lengthy. A second reason was to ascertain the characteristics of the pain complaint that was most problematic for each participant.
Care-Seeking Medical care-seeking was a very common option for many people participating in our survey and this result agrees with several studies despite different methodological approaches. Some authors have shown that general practitioners are visited by more than half of the patients experiencing pain,3,4 showing that, in spite of the consultation of other health professionals, such as dentists, chiropractors, pharmacists or physical therapists,4,21 physicians are still the preferred choice of many patients when afflicted by pain. The most common behavior is to seek medical care as well as self-care and complementary medicines or other therapeutic options. Seeking medical care is gender- and age-related, as women and aged people more frequently visited their physicians. There is also a relationship between pain characteristics: people with chest pain, pain in the legs, back or chest are more prone to seek medical care. These results agree with those reported by Taylor et al.4 in the general population of the USA.
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Most people were treated in public primaryhealth centers or hospitals, mainly due to the existence of a free National Health Service (NHS) for all Spaniards. As expected, the main treatment was drug therapy, followed by physical therapy and surgery, but these options were utilized much less. The use of analgesics by medical prescription is very common in developed countries. For instance, analgesic drugs are the most commonly prescribed drugs by Spanish physicians,22 and almost ten percent of the Swedish general population uses physician prescribed analgesics.23 The number of physician visits was high and, as expected, an age-related increase was seen. This finding might be explained by the fact that Spanish NHS gives medical assistance and treatment to almost all Spaniards and is virtually free for all of them. These data suggest that pain is a medical condition that consumes a large amount of economic resources from the national health systems in countries where all nationals are covered. When separately analyzing drug therapy, it was observed that many patients were treated with at least one analgesic drug, the most commonly prescribed being paracetamol, diclofenac, salicylates and metamizol. These data are consistent with previous studies performed in the same area.22,25 The prevalent use of diclofenac and metamizol seem somewhat idiosyncratic, as other countries are prone to use different drugs. For instance, in France, most analgesic drugs prescribed by physicians are salicylates and paracetamol.26 These data suggest that there may be cultural patterns in the prescription of analgesics, which are independent of medical evidence and the recommendations of international consensus conferences.
Self-Medication The present study shows that self-medication is a frequent therapeutic option for many people, but this is not an unexpected finding. Common sense and experience show that people with pain will rely on their own treatments before asking for medical advice, as it has been shown in the USA4 and Sweden.23,24 In fact, our data on self-medication were very similar to those reported in these studies and by other authors working in our country.27–29 Nonetheless, some characteristics merit further commentaries. The population of our study probably uses analgesics often, as indicated by the fact that
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they could easily recall the name of the drug they took and by the fact that they chose the drug themselves. Self-medication was frequently successful in ameliorating their pain; this finding suggests that people were using these drugs to treat minor pains, such as headaches and toothaches,4,25,26,30 and those of moderate intensity. Some demographic data are interesting to outline, such as the more frequent use of selfmedication by young women, as Antonov and Isacson23,24 also found. However, a finding difficult to explain is the choice of drugs. As expected, salicylates and paracetamol were the drugs most commonly used, as in the USA;4 however, differences by gender arose as women used both drugs equally, whereas men largely preferred salicylates. As paracetamol was more commonly used in treating abdominal pain (most of which was dysmenorrea11), it might be suggested that this may account for such a discordance. Even if one accepts this possibility, other explanations should be considered. Our study also shows that paracetamol use was more prevalent in younger people, whereas older people used salicylates more frequently. Taken together, this evidence might suggest a trend to avoid salicylates by self-medication seen in young people and women, probably due to a higher awareness of their potential side effects in both groups. The widespread use of paracetamol is a relatively recent event in Spain,31 as compared to the long tradition of preferring paracetamol over salicylates in the USA and the United Kingdom.32
Complementary Therapies Few studies have analyzed the use of complementary therapies in pain complaints in any detail, but it seems that it should be a frequent option for many patients16,33 and, at least in cancer and terminally ill patients, they might offer some help.34 In the USA, some studies shown that 34% of the general population has been using complementary medicine for the treatment of a variety of ailments17 and that the use of several procedures at the same time is not uncommon.18 Our study reports that one-fifth of the people used at least one remedy which might be classified as a complementary medicine, and their use was more common in middle-aged women with severe back or abdominal pain. These characteristics suggest that the most dis-
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tressed patients use such treatments and it has been suggested that the use of complementary medicine might be a marker of greater psychosocial distress and lower quality of life.35 This is not an uncommon finding, as Eisenberg et al.17 have shown that 34% of their patients have used one or more complementary therapies within one month of their interview. Many complementary therapies such as relaxation techniques, chiropractic, massage, imagery, spiritual healing, herbal medicine, energy healing, biofeedback, hypnosis, homeopathy, acupuncture and a long list of other home remedies are used to relieve many ailments. In our study, we have found that massage, relaxation techniques, acupuncture and herbal remedies were the main treatments used, and these results are similar to those found by Paramore18 for all types of health problems in the general population of the US.
Physical Therapy Physical therapy is often used as a companion to other treatments, as our study shows. Previous surveys did not analyze the characteristics of patients who followed this treatment. For instance, Andersson et al.16 reported that 7.2% of chronic pain patients were treated with physical therapy, whereas Brattberg8 described this treatment in 21% of her patients with persistent pain. Other authors have described the use of physical therapy but no quantitative data were reported.3,14,15,36 Physical therapy is often employed by back pain patients in many countries. Dreiser et al.37 have shown that 36% of the patients of French general practitioners are treated in this way, as well as 27% of patients of French rheumatologists. In the general population of Great Britain, however, physical therapy was only used in 9.8% and osteopathy in 4.5%.21 These differences might be a consequence of the different definition of physical therapy, but might also be from cultural trends. For instance, osteopathy is more popular in Anglo-Saxon countries than in Latin populations. In our study, physical therapy is mainly used as a long-term treatment by both men and women of almost all ages with severe back pain. These treatments result in only mild relief, even when it is used jointly with other treatments, as it is commonly the case. These data might be explained by the fact that physical therapy is only used as a final
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treatment when other therapies fail and the pain is very difficult to treat.
Hospital-Based Treatment This therapeutic option was rarely reported in our survey, and it was very expensive when it was used. This is justified by the fact that people who needed a hospital-based treatment had been hospitalized many times and their stay was often longer than two weeks. As expected, pain was frequently severe and was located in the chest. This location suggests a cardiovascular etiology and is then unrelated with the more common skeletal origin of the majority of chronic pain patients.
No Treatment Pain was not treated in young men, in those with mild pain and in those with pain mainly located in arms and teeth. These data suggest that such people considered their painful events to be such of low importance that they would neglect their treatment. Our data were slightly higher than those observed by Taylor and Morency4 in the general population of the USA, but lower than those reported by Elliott et al.38 in British patients with chronic pain. This may be explained by the helplessness that some patients with chronic pain feel in overcoming their pain which makes them avoid further attempts to treat it. However, there may also be a cultural component to this type of behavior. Some studies in our area addressing the treatment of common health disorders have shown that young men show a trend towards avoiding treatment for such ailments.29 In conclusion, our study shows that pain treatment is a common motivation for patients to seek medical care and for using drugs in Catalonian population. The direct consequence of this finding is that pain should be regarded as one of the most important health problems in Western countries. Additionally, consultation of a physician is often used with other therapies, such as self-medication and complementary medicines and, as a consequence, the economic costs of pain are still higher than calculated only by NHS expenditures. A second finding is that the characteristics of patients using each therapeutic approach differ when considering the type of pain complaint, age or gender. As a consequence, interventions may be targeted not only to specific pain complaints but also to
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particular populations to improve therapeutic behaviors. Our data may be used to improve the characteristics of pain treatment and to allow a more efficient use of available resources.
Acknowledgments
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9. James FR, Large RG, Bushnell JA, Wells JE. Epidemiology of pain in New Zealand. Pain 1991; 44: 279–283. 10. Anderson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic pain in a geographically defined general population: studies of differences of age, gender, social class and pain localizations. Clin J Pain 1993; 9: 174–182.
This study was supported by a grant contract between the Autonomous University of Barcelona and Química-Farmacéutica Bayer (Spain). The authors would especially like to thank Fèlix Berrocal in obtaining financial resources. The authors also wish to thank Antònia Fernández, Carme García and Carme Castells for their contributions during the telephone interview stage and Montserrat Cañellas, Montserrat Rué, Mercedes Campillo and Pere Escudé for their collaboration in various parts of the study. Uraina Clark and Chuck Simmons helped greatly with the English translation and review of the manuscript. We would also like to mention the Institut d’Estadística de Catalunya for allowing us access to the census figures needed for the study. And, finally, we would like to thank all of the people who kindly gave us their time to participate in the telephone interview.
11. Bassols A, Bosch F, Campillo M, Cañellas M, Baños JE. An epidemiological comparison of pain complaints in the general population of Catalonia (Spain). Pain 1999; 83:9–16.
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1. Frolund F, Frolund C. Pain in general practice. Pain as a cause of patient-doctor contact. Scand J Prim Health Care 1986; 4:97–100. 2. Wall PD, Jones M. Defeating pain. The war against a silent epidemic. New York: Plenum,1991. 3. Crook J, Rideout E, Browne G. The prevalence of pain complaints in a general population. Pain 1984;18:299–314. 4. Taylor H, Morency N. The Nuprin pain report. Report No.851017, New York, Louis Harris and Associates, 1985. 5. Andersen S, Worm-Pedersen J. The prevalence of pain in a general population. Pain 1987; (Suppl 4): S332. 6. Von Korff M, Dworkin S, Le Resche L. Graded chronic pain status: an epidemiologic evaluation. Pain 1990; 40:279–291. 7. Bowsher D, Rigge M, Sopp L. Prevalence of chronic pain in the British population: a telephone survey of 1037 households. Pain Clinic 1991; 4: 223–230. 8. Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden. Pain 1989; 37:215–222.
12. Sternbach RA. Survey of pain in the United States: the Nuprin pain report. Clin J Pain 1986; 2: 49–53. 13. Ballina FJ, Hernández R, Martín P, Fernández J, Cueto A. Epidemiology of musculoskeletal complaints and use of health services in Asturias, Spain. Scand J Rheumatol 1994;23:137–141. 14. von Korff M, Dworkin SF, Le Resche L, Kruger A. An epidemiologic comparison of pain complaints. Pain 1988; 32:173–183. 15. Chrubasik S, Junk H, Zappe HA, Stutzke O. A survey on pain complaints and health care utilization in a German population sample. Eur J Anaesthesiol 1998;15:397–408. 16. Andersson HI, Ejlertsson G, Leden I, Schersten B. Impact of chronic pain on health- care seeking, self-care, and medication. Results from a population-based Swedish study. J Epidemiol Community Health. 1999;53:503–509.
18. Paramore LC. Use of alternative therapies: estimates from the 1994 Robert Wood Johnson Foundation of National Access to Care Survey. J Pain Symptom Manage 1997;13:83–89. 19. Izquierdo MJ, Miquélez F, Subirats M. Condicions de vida i hàbits de la població de l’Àrea Metropolitana de Barcelona. Barcelona: Universitat Autónoma de Barcelona, 1988. 20. Becker N, Sjøgren P, Bech P, Olsen AK, Eriksen J. Treatment outcome of chronic non-malignant pain patients in a Danish multidisciplinary pain center compared to general practice: randomized controlled trial. Pain 2000; 84:203–211. 21. Hillman M, Wright A, Rajaratnam G, Tennant A, Chamberlain MA. Prevalence of low back pain in the community: implications for service provision in Bradford, UK. J Epidemiol Community Health. 1996;50:347–352. 22. Anonymous. Medicamentos más consumidos en España. Ministerio de Sanidad. Anuario El País 1999. 23. Antonov K, Isacson D. Use of analgesics in Sweden—the importance of sociodemographic factors, physical fitness, health and health-related factors, and working conditions. Soc Sci Med 1996;42:1473–1481.
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24. Antonov KI, Isacson DG. Prescription and nonprescription analgesic use in Sweden. Ann Pharmacother 1998;32:485–494.
32. Mann CC, Plummer ML. The aspirin wars. Money, medicine and 100 years of rampant competition. New York: Alfred A Knopf, 1991.
25. Bosch F, Toranzo I, Baños JE. A survey of pain complaints and treatment by general practitioners in the Spanish public health organization. Clin J Pain. 1990; 6:206–211.
33. Brattberg G. Selecting patients for pain treatment: applying a model to epidemiological data. Clin J Pain 1990;6:37–42.
26. Menard G, Allain H, Le Roho S, Morel G, Beneton C. Enquête d’un jour en officine sur la consommation d’antalgiques et d’antipyrétiques. Therapie 1993;48:263–267.
34. Pan CX, Morrison RS, Ness J, Fugh-German A, Leipzig RM. Complementary and alternative medicine in the management of pain, dyspnea, and nausea and vomiting near the end of life: a systematic review. J Pain Symptom Manage 1999; 20:374–387.
27. Nebot M, Llauger MA. Autocuidado de los trastornos comunes de salud: resultados de una encuesta telefónica en la población general. Med Clin (Barc) 1992;99:420–424.
35. Burstein HJ, Gelber S, Guadagnoli E, Weeks JC. Use of alternative medicine by women with earlystage breast cancer. N Eng J Med 1999; 340:1733– 1739.
28. Del Río MC, Prada C, Alvarez J. The use of medication by the Spanish population. Pharmacoepidemiol Drug Safety. 1997;6:41–48.
36. Català E, Reig E. Prevalence of pain in the Spanish population: a survey of 4750 households. Int Monitor 1998;10:142.
29. Tejedor N, Zafra E, Sánchez del Viso Y, et al. Trastornos comunes de salud: autocuidado y automedicación. Aten Primaria.1995;16:27–32. 30. Baños JE, Bosch F, Toranzoi. La automedicación con analgésicos. Estudio en el dolor odontológico. Med Clin (Barc) 1991; 96:248–251.
37. Dreiser RL, Maheu E, Ghozlan R, et al. An epidemiological study of diagnostic and therapeutic strategies in office practice patients with subacute or chronic pain in the thoracic or low back. Comparison of practices in primary care and rheumatology settings. Rev Rhum (English Edition) 1997;64:26–34.
31. Carvajal A, Martin L, Martin I, Velasco A. Aspirin and paracetamol: changing pattern of use in Spain. Pharmacoepidemiol Drug Safety 1995;4:381–382.
38. Elliot AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet 1999;354:1248–1252.
Journal of Pain and Symptom Management
Vol. 23 No. 4 April 2002
Original Article
How Does the General Population Treat Their Pain? A Survey in Catalonia, Spain Antònia Bassols, MD, Fèlix Bosch, MD and Josep-Eladi Baños, MD Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Bellaterra, Spain
Abstract Several epidemiological studies have shown that pain is a very common complaint in patients who seek medical care. However, the characteristics of how pain is treated in the general population have been studied less. The present survey was conducted to describe and analyze how the general population of Catalonia (Spain) approaches the treatment of their pain complaints. The study was carried out in 1964 adults who were surveyed by phone about the presence of painful events in the last six months, the intensity and location of their pain, what they did to treat their pain, and their resulting level of relief. Data were compared by age and gender. Pain prevalence was high (78.6%) and more frequent in women. The therapeutic strategy most commonly used was a visit to the physician (66.3%), followed by self-medication (27.6%) and alternative medicines (20.5%). Drugs were the primary treatment used by physicians (86.5%), followed by physical therapy (18.1%). Pain in the extremities, back and neck pain were often unsuccessfully treated. Self-medication was often performed with acetylsalicylic acid and paracetamol (acetaminophen), and was commonly used in conjunction with other therapeutic approaches (51.9%). Age (low use of paracetamol in the elderly) and gender (low use of paracetamol in men) were related to the type of drug used in self-medication. Older men, and those with severe pain located in the chest, required hospital admission more commonly. In conclusion, pain is a common reason for seeking medical care and using drugs. Therapeutic approaches are often related to the type of pain, but also to age or gender. Knowledge of these characteristics may allow for a more efficient use of available resources. J Pain Symptom Manage 2002;23:318–328. © U.S. Cancer Pain Relief Committee, 2002. Key Words General population, pain treatment, pain prevalence, alternative medicines, self-medication
Introduction Pain is a very common complaint in patients who seek the help of health professionals.1 This symptom can severely affect the patients’
Address reprint requests to: Josep-Eladi Baños, MD, Department of Pharmacology, Therapeutics and Toxicology, Faculty of Medicine, Autonomous University of Barcelona 08193, Bellaterra, Spain. Accepted for publication: July 18, 2001 © U.S. Cancer Pain Relief Committee, 2002 Published by Elsevier, New York, New York
quality of life, and it is also becoming a true social disease, as some pains, like low back pain, are becoming highly prevalent. Wall defined pain as the silent epidemic of Western societies.2 Several epidemiological studies have described the main characteristics of pain in the general population.3–11 These surveys report an elevated prevalence of current and chronic pain, as well as a high degree of associated disabilities and limitations. The direct conse0885-3924/02/$–see front matter PII S0885-3924(01)00415-8
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quences for the community are a costly increase of health and social expenditures to cover medical services and disability benefits.12–13 These costs are difficult to quantify precisely and studies are needed to calculate them. One method of evaluating the medical costs of pain in the general population is to investigate how these complaints are treated. Several authors have employed this approach and their results show that pain sufferers visit several health professionals, and use several therapeutic strategies at the same time.3,4,8,14–16 They also use complementary approaches.17,18 However, these studies did not accurately analyze the characteristics of each treatment by the type of pain complaint or the sociodemographic features of patients. This information might help to characterize the different profiles of each population with a specific type of pain, and aid in the development of specific health interventions. An epidemiological study was performed in the general population of Catalonia, a region in northeastern Spain. The first part of the study, which analyzed pain prevalence and characteristics, has been published elsewhere.11 In this paper, we report the second segment of our study, which described and analyzed how people treat their pain.
Methods Setting The study was carried out in Catalonia, a region in the northeast of Spain with an approximate population of 6,000,000. A representative sample of the adult population (18 years of age and older) was chosen at random and divided into age, sex and residential area groups. The figures were taken from the 1991 electoral census, which was made available by the regional statistics center (Institut d’Estadística de Catalunya). Name, age, address and place of residence were listed on the census form. The telephone numbers were obtained by going through the phone books made available by the Spanish phone company (Compañía Telefónica Nacional de España). People excluded from the study were those without a telephone, those who lived in closed institutions (hospitals, prisons, asylums, nursing homes), the homeless, those of no fixed address, and those with mental or physical disabilities which made a telephone
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interview impossible. People were also excluded if we were unable to contact them by phone after 20 attempts in one month.
Sample Size Calculation The size of the sample was obtained by considering a 95% confidence level, a 35% foreseeable pain prevalence, a degree of accuracy of 0.06, and eight groups of stratification (four age intervals by genders). These assumptions gave 243 individuals in each group; thus, the required number for the eight groups was 1944 individuals. Complete data were collected from 1964 individuals. All calculations were based on this final figure. The final sample was taken from a larger sample of 5,000 individuals, which was used to overcome the following limitations: between 10% and 20% of the Catalonian population have no telephone line,19 50% of women are not listed in phone books, and 30% of our initial interviewees were not able to be contacted for various reasons. Each excluded individual was substituted with someone of the same demographic characteristics to achieve the proper distribution. Each group had a predetermined number of individuals established to reflect the actual demographic characteristics of the Catalonian population. Letters were sent and individuals were phoned consecutively as they appeared in the census list of 5,000 individuals until every group was completed. To achieve this goal, a total number of 2,835 letters were sent, but only 2,142 individuals were found. Among them, 1,964 agreed to participate in the survey, resulting in an acceptance rate of 91.7%.
Procedure and Variables Collections of case report forms were carried out via telephone interview. A week before the first phone call, a letter was sent to each possible participant to explain the goals of the study and its characteristics. An initial trial with 100 interviews was undertaken to establish the feasibility of conducting the survey by phone and to sort out any possible difficulties. The main sociodemographic data, pain presence, and the treatment (pharmacological and non-pharmacological) used to treat pain complaints were recorded. All possible variables, along with different categories and subcategories, were later established. The following definitions were used throughout the study.
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Pain prevalence and intensity. Patients were asked if they experienced any pain in the last six months, regardless of its intensity and duration. The presence or absence of pain and its bodily location were determined. When more than one location was reported, the interviewee was asked which had been the most troublesome, and its pain intensity was evaluated by means of a Numerical Scoring Scale (NSS, 1 very mild pain, 10 excruciating pain). All subsequent data obtained related only to this troublesome pain for practical purposes. Pain management strategies. The following therapeutic approaches were considered: visits to a physician (National Health Service or private practice, frequency, type of treatment, drug prescribed), self-medication (drug, degree of improvement), physical therapy, complemen-
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tary therapies, no treatment and/or hospital referral. The degree of improvement with medical treatment was categorized as none, slight, moderate, much or complete. Patients were asked if they tried any management strategy for the pain complaint in the last six months. Sociodemographic data of the sample. Sex, age, place of residence (rural, intermediate or urban sites), civil status, occupational status, social class and level of education were the variables studied (see Bassols et al.11). The categories of sociodemographic variables are shown in Table 1.
Statistical Analysis The survey data were assembled in the software DBASEIII plus and later analysis was carried out using the statistical package SPSS/
Table 1 Sociodemographic Characteristics and Prevalence of Pain
Sample Gender Age (years)
Place of residencea Civil statusb
Educationa
Occupational statusa
Social classa,b
Female Male MeanSD (range) By intervals: 20–30 31–50 51–70 71–91 Rural Intermediate Urban Unmarried Married Widowed Separated/divorced Illiterate Primary (not finished) Primary (finished) Secondary University Employed Unemployed Retired Student Home duties I II III IV V VI
Total (%)
Prevalence (%)
1964 988–50.3 976–49.7 47.517 (20–91)
78.6 85.6 71.5 47.217 [49.718]c
430–21.9 685–34.9 628–32.0 220–11.2 115–5.8 263–13.4 1586–80.8 444–22.7 1307–66.9 150–7.7 52–2.7 83–4.3 305–16.0 802–42.1 411–21.6 305–16.0 1015–52.5 130–6.7 426–22.0 59–3.1 303–15.7 91–4.7 227–11.7 251–13.0 594–30.7 63–3.2 712–36.7
80.5 80.1 77.4 73.6 73.9 75.7 79.4 78.6 78.7 77.3 80.8 86.7 77.7 78.7 77.4 79.7 77.5 76.2 75.1 84.7 86.9 75.8 77.5 77.7 80.3 85.7 77.8
aThe following data were not obtained in all of the interviewees, therefore their n values are smaller than the total sample: civil status (1953); education (1906); occupational status (1933) and social class (1938). bFor details on social class categories, see Bassols et al.11 cIn brackets, mean age and SD for people without pain (n 420).
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PC. Given the exploratory epidemiological nature of the study, the data are presented as descriptive statistics [percentage, mean standard deviation (SD)]. Mean comparisons were calculated with the Student’s t-test and analysis of variance (ANOVA). The 2 test was used for comparing percentages. A 5% significance level was accepted for all tests.
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(36.8%) were the most frequent sites described as painful. Pain prevalence was also related to age, and young people had a higher prevalence than older people.
Characteristics of Pain Management The therapeutic strategy most commonly used was a visit to the physician (66.3%) followed by self-medication (27.6%) and complementary therapies (20.5%). Other treatments commonly used were physical therapy (13.8%) and hospital admission (2.6%). However, 10.6% of all people did not treat themselves at all (Table 2). People often used more than one therapeutic option, with a mean of 1.4. The characteristics of the visit to physician and self-medication are analyzed in the next section. A relationship was observed when comparing sociodemographic data with type of treatment. People who did not follow any treatment were mainly men, young and single. Regarding the characteristics of pain, those of mild or moderate intensity and those affecting the teeth or legs often remained untreated. Middle-aged women more often used complementary therapies, commonly coupled with other treatments (87%). When complemen-
Results Characteristics of the Sample and Pain Prevalence As Table 1 shows, 1964 people were interviewed, of which 50.3% were women; the mean age of the sample was 47.517 years (range 20–91). The majority of participants was from urban areas (80.7%), were married (66.9%), were educated through primary school (42.1%), were employed (52.5%) and belonged to the middle class (31.3% in Group IV). The pain prevalence was high (Table 1), as 78.6% (1453) of the interviewees claimed to have or to have had pain in one or more locations during the 6 months prior to the interview. Women had a higher prevalence (85.6% vs. 71.5% in men) and in more locations (3.4 vs. 2.7). Back (50.9%), head (40.2%) and legs
Table 2 Therapeutic Strategies by Gender and Age Total (%)
Gender(%)
P
Agea Group (%)
P
1023–66.3
F 69.3 M 62.6
0.001
0.001
Self-medication
403–27.6
F 28.2 M 23.6
0.05
Complementary medicine
316–20.5
F 24.9 M 15.2
0.001
Physical therapy
175–13.8
F 12.2 M 10.3
NS
No treatment
163–10.6
F 7.2 M 14.6
0.001
F 1.4 M 4.0
0.01
1–47.8 2–63.4 3–76.1 4–85.8 1–35.1 2–28.6 3–21.4 4–13.0 1–14.2 2–24.0 3–21.4 4–18.5 1–4.9 2–12.2 3–14.6 4–12.3 1–17.1 2–10.9 3–7.0 4–6.2 1–0.9 2–2.0 3–3.7 4–4.9
Visit to the physician
Hospital-based treatment
40–2.6
F female, M male., NS not significant. aAge groups: 1 (20–30); 2 (31–50); 3 (51–70); 4 (70).
0.001
0.01
0.001
0.001
0.05
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tary therapies were chosen, pain was severe and was located in neck, back and abdomen. The most frequent complementary therapies used were herbal teas, massage, focal heat and acupuncture (Tables 2–4). Middle-aged people, both men and women, frequently used physical therapy. The intensity of their pain was high, mainly located in the back, neck, and legs. Physical therapy procedures most commonly used were physical exercise, electrotherapy (ultrasound, short-wave, microwave, laser), superficial heat and massage (Table 2–4). Older men, and those with severe pain in the chest location more commonly needed hospital admission (Table 2–4).
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face (80.0%), legs (82.1%) and back pain (71.9%), as Table 3 shows. Most interviewees went to primary-care centers of the National Health Service (72.6%). Almost a quarter of them (23.3%) also visited private physicians. This behavior was especially important in those with toothaches, and most of these people chose private medical assistance as their first option of treatment (79.1%). Drugs were the most frequently prescribed treatment (86.5%), followed by physical therapy and surgical procedures. A large number of analgesic drugs was used, and their proprietary names frequently were unknown by the interviewees (18.8%). The most frequently reported were simple analgesics (paracetamol [acetaminophen] mainly) and nonsteroidal anti-inflammatory drugs (NSAIDs) (69.7%), followed by a large list which included antibiotics, antacids (almagate was the most frequently prescribed), psychotropic drugs, calcium compounds, and corticosteroid drugs (labeled as “other” in Table 4). The type of analgesic drug that was prescribed related to the pain site (p 0.001). For back, leg or arm pain, the main drugs used were diclofenac, paracetamol and salicylates. Paracetamol, salicylates and propifenazone were pre-
Visit to the Physician As commented earlier, a visit to the physician was the therapeutic option most frequently used. Almost half (44.8%) of the people also chose complementary or physical therapies. Women visited the physician more frequently (p 0.001) and older women did so more than younger ones (p 0.001). Pain was scored as severe (NSS 6.41.9), mainly affecting chest, legs and face. People who visited the physician most often were those affected by chest (88.9%),
Table 3 Pain Characteristics by Therapeutic Strategy
Pain intensitya Specific Strategy Rest of Strategies P Values Pain locationsb Back Head Abdomen Legs Teeth Neck Arms Chest Face P Values
N/n (%) 1000/466 (46.6) 825/367 (44.5) 359/124 (34.6) 724/235 (32.5) 429/104 (24.2) 625/136 (21.8) 531/87 (16.4) 191/18 (9.5) 83/5 (6.0)
Visit to the Physician N 1023
Self Medication N 403
Complementary Medicine N 316
Physical Therapy N 175
No Treatment N 163
Hosp-Based Treatment N 40
6.41.9 (1–10) 5.31.7 (1–10) 0.001
5.81.7 (1–10) 6.12.0 (1–10) 0.01
6.51.9 (2–10) 5.91.9 (1–10) 0.001
6.62.0 (2–10) 5.91.9 (1–10) 0.05
4.81.7 (1–10) 6.21.9 (1–10) 0.001
7.62.2 (3–10) 6.01.9 (1–10) 0.001
71.9 47.4 69.4 82.1 64.4 68.4 62.1 88.9 80.0 0.001
14.6 52.3 21.8 10.2 34.6 22.8 24.1 22.2
24.7 16.1 24.2 20.4 1.9 29.4 16.1 22.2 60.0 0.001
22.9 0.3 0.8 14.5 1.0 14.7 13.8
13.9 5.2 6.5 9.4 16.3 11.0 18.4 5.6
2.8 0.5 6.5 3.8
0.001
0.001
—
0.001
— —
—
—
0.7 1.2 27.8 20.0 0.001
aPain intensity was measured by the numerical scoring scale (1–10) and their values are expressed as mean SD (range). Pain intensity of each specific therapeutic strategy was compared with the reported by patients treated with the other therapeutic strategies. bN: number of people with pain in the last 6 months; n: pain site considered as the most troublesome (in parentheses: percentage of the troublesome pain over all pains at this location). In the columns of therapeutic strategies by pain location, values are expressed as the percentage of people in each pain location who followed every strategy.
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Table 4 Specific Therapeutic Strategies N Visit to the physician
1023
Self-medication
403
Complementary medicine
316
Physical therapy
175
ferred to treat headache. Metamizol, diclofenac and paracetamol were, in this order, the most frequent choices for toothaches, whereas paracetamol, metamizol and piroxicam were used in abdominal pain treatment. There was a large variation in the degree of relief experienced by pain sufferers after treatment and significant differences were observed when pain localization was considered (p 0.001). People reported good pain relief in toothaches, headaches and abdominal pain, whereas pain in the extremities, back and neck pain were often unsuccessfully treated (Fig. 1).
Treatments
N
Percentage
Drug therapy: Paracetamol Diclofenac Salicylates Metamizol Piketoprofen Other (5%) Physical therapy Surgery Other
885 204 188 114 52 41 138 185 69 148
86.5 27.7 25.5 15.4 7.1 5.1 18.7 18.1 6.7 14.5
Acetylsalicylic acid Paracetamol Metamizol Other (3%) Herbal medicines Massage Heat Acupuncture Folk remedies Naturopathy Quack healer Homeopathy Other (5%) Exercise Electrotherapy Heat Massage Other (5%)
198 156 14 22 75 62 58 45 29 24 17 16 69 133 84 33 29 21
44.5 35.1 3.1 17.3 23.7 19.6 18.3 14.2 9.2 7.6 5.4 5.1 21.8 75.1 47.5 18.6 16.4 11.8
In contrast to those taking drugs prescribed by their physicians, most self-medicating people were able to report the proprietary name of the drug which they were taking (96.7%). Pain relief was reported as good by most people who self-medicated (86.6%). The most commonly used drugs were acetylsalicylic acid (ASA) and paracetamol (Table 4).
Self-Medication Self-medication was the choice of 27.6% of the people, and in more than half of them (51.9%), it was used jointly with other therapeutic approaches. Women (p 0.05) and young people (p 0.001) used self-medication most frequently. People who self-medicated reported lower pain levels (NSS 5.81.7) than those who did not (NSS 6.1 2.0, p 0.01). This behavior was more common in headaches (52.3%) and toothaches (34.6%) sufferers (Table 3).
Fig. 1. Pain relief after medical treatment by pain location. In parentheses, number of interviewees who reported the level of their pain relief after visiting their physician.
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Further analysis was conducted to consider the differences of use of each analgesic drug by age and gender (Figs. 2 and 3). The use of ASA increased in accordance with person’s age, whereas paracetamol followed an inverse pattern. When gender was considered, women used ASA (48.8%) and paracetamol (39.2%) similarly. However, men reported a clear preference for ASA (60.8%) over paracetamol (21.5%).
Discussion The main goal of our study is to analyze how the general population copes with their pain complaints in their everyday life. Few studies have been devoted to this topic and, in general, attention has been centered on chronic pain patients at pain centers21 or in primary health care.16 But chronic pain is only a small part of all pain complaints. In fact, many people with acute ailments do not seek medical care and self-treat with drugs or other nonpharmacological therapies. For instance, few women with menstrual pain will ask for advice every month and instead use known remedies to get relief. The same would probably be true for many sufferers of headaches, including migraine. The main consequence of such a situation is that the presence of pain might be overlooked in many people, as acute pain and chronic pain not considered as such (e.g., menstrual pain or migraine) are under-represented. Our survey has tried to avoid this limi-
Fig. 2. Drugs used in self-medication according to the age of interviewees. Other drugs included metamizol, diclofenac and a large number of NSAIDs and analgesic drugs. ASA Acetylsalicylic acid.
Fig. 3. Drugs used in self-medication by gender. In parentheses, number of interviewees who self-medicated with each drug. ASA Acetylsalicylic acid.
tation by asking all people if any pain complaint was present and how they treated it. Some characteristics of our study are different from other surveys on pain prevalence. Although data on pain complaints in any location were obtained,11 information on pain treatment was only obtained for the most troublesome pain. The reason for this choice was the need to shorten the phone interview and to avoid the unreliability of data if this was too lengthy. A second reason was to ascertain the characteristics of the pain complaint that was most problematic for each participant.
Care-Seeking Medical care-seeking was a very common option for many people participating in our survey and this result agrees with several studies despite different methodological approaches. Some authors have shown that general practitioners are visited by more than half of the patients experiencing pain,3,4 showing that, in spite of the consultation of other health professionals, such as dentists, chiropractors, pharmacists or physical therapists,4,21 physicians are still the preferred choice of many patients when afflicted by pain. The most common behavior is to seek medical care as well as self-care and complementary medicines or other therapeutic options. Seeking medical care is gender- and age-related, as women and aged people more frequently visited their physicians. There is also a relationship between pain characteristics: people with chest pain, pain in the legs, back or chest are more prone to seek medical care. These results agree with those reported by Taylor et al.4 in the general population of the USA.
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Most people were treated in public primaryhealth centers or hospitals, mainly due to the existence of a free National Health Service (NHS) for all Spaniards. As expected, the main treatment was drug therapy, followed by physical therapy and surgery, but these options were utilized much less. The use of analgesics by medical prescription is very common in developed countries. For instance, analgesic drugs are the most commonly prescribed drugs by Spanish physicians,22 and almost ten percent of the Swedish general population uses physician prescribed analgesics.23 The number of physician visits was high and, as expected, an age-related increase was seen. This finding might be explained by the fact that Spanish NHS gives medical assistance and treatment to almost all Spaniards and is virtually free for all of them. These data suggest that pain is a medical condition that consumes a large amount of economic resources from the national health systems in countries where all nationals are covered. When separately analyzing drug therapy, it was observed that many patients were treated with at least one analgesic drug, the most commonly prescribed being paracetamol, diclofenac, salicylates and metamizol. These data are consistent with previous studies performed in the same area.22,25 The prevalent use of diclofenac and metamizol seem somewhat idiosyncratic, as other countries are prone to use different drugs. For instance, in France, most analgesic drugs prescribed by physicians are salicylates and paracetamol.26 These data suggest that there may be cultural patterns in the prescription of analgesics, which are independent of medical evidence and the recommendations of international consensus conferences.
Self-Medication The present study shows that self-medication is a frequent therapeutic option for many people, but this is not an unexpected finding. Common sense and experience show that people with pain will rely on their own treatments before asking for medical advice, as it has been shown in the USA4 and Sweden.23,24 In fact, our data on self-medication were very similar to those reported in these studies and by other authors working in our country.27–29 Nonetheless, some characteristics merit further commentaries. The population of our study probably uses analgesics often, as indicated by the fact that
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they could easily recall the name of the drug they took and by the fact that they chose the drug themselves. Self-medication was frequently successful in ameliorating their pain; this finding suggests that people were using these drugs to treat minor pains, such as headaches and toothaches,4,25,26,30 and those of moderate intensity. Some demographic data are interesting to outline, such as the more frequent use of selfmedication by young women, as Antonov and Isacson23,24 also found. However, a finding difficult to explain is the choice of drugs. As expected, salicylates and paracetamol were the drugs most commonly used, as in the USA;4 however, differences by gender arose as women used both drugs equally, whereas men largely preferred salicylates. As paracetamol was more commonly used in treating abdominal pain (most of which was dysmenorrea11), it might be suggested that this may account for such a discordance. Even if one accepts this possibility, other explanations should be considered. Our study also shows that paracetamol use was more prevalent in younger people, whereas older people used salicylates more frequently. Taken together, this evidence might suggest a trend to avoid salicylates by self-medication seen in young people and women, probably due to a higher awareness of their potential side effects in both groups. The widespread use of paracetamol is a relatively recent event in Spain,31 as compared to the long tradition of preferring paracetamol over salicylates in the USA and the United Kingdom.32
Complementary Therapies Few studies have analyzed the use of complementary therapies in pain complaints in any detail, but it seems that it should be a frequent option for many patients16,33 and, at least in cancer and terminally ill patients, they might offer some help.34 In the USA, some studies shown that 34% of the general population has been using complementary medicine for the treatment of a variety of ailments17 and that the use of several procedures at the same time is not uncommon.18 Our study reports that one-fifth of the people used at least one remedy which might be classified as a complementary medicine, and their use was more common in middle-aged women with severe back or abdominal pain. These characteristics suggest that the most dis-
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tressed patients use such treatments and it has been suggested that the use of complementary medicine might be a marker of greater psychosocial distress and lower quality of life.35 This is not an uncommon finding, as Eisenberg et al.17 have shown that 34% of their patients have used one or more complementary therapies within one month of their interview. Many complementary therapies such as relaxation techniques, chiropractic, massage, imagery, spiritual healing, herbal medicine, energy healing, biofeedback, hypnosis, homeopathy, acupuncture and a long list of other home remedies are used to relieve many ailments. In our study, we have found that massage, relaxation techniques, acupuncture and herbal remedies were the main treatments used, and these results are similar to those found by Paramore18 for all types of health problems in the general population of the US.
Physical Therapy Physical therapy is often used as a companion to other treatments, as our study shows. Previous surveys did not analyze the characteristics of patients who followed this treatment. For instance, Andersson et al.16 reported that 7.2% of chronic pain patients were treated with physical therapy, whereas Brattberg8 described this treatment in 21% of her patients with persistent pain. Other authors have described the use of physical therapy but no quantitative data were reported.3,14,15,36 Physical therapy is often employed by back pain patients in many countries. Dreiser et al.37 have shown that 36% of the patients of French general practitioners are treated in this way, as well as 27% of patients of French rheumatologists. In the general population of Great Britain, however, physical therapy was only used in 9.8% and osteopathy in 4.5%.21 These differences might be a consequence of the different definition of physical therapy, but might also be from cultural trends. For instance, osteopathy is more popular in Anglo-Saxon countries than in Latin populations. In our study, physical therapy is mainly used as a long-term treatment by both men and women of almost all ages with severe back pain. These treatments result in only mild relief, even when it is used jointly with other treatments, as it is commonly the case. These data might be explained by the fact that physical therapy is only used as a final
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treatment when other therapies fail and the pain is very difficult to treat.
Hospital-Based Treatment This therapeutic option was rarely reported in our survey, and it was very expensive when it was used. This is justified by the fact that people who needed a hospital-based treatment had been hospitalized many times and their stay was often longer than two weeks. As expected, pain was frequently severe and was located in the chest. This location suggests a cardiovascular etiology and is then unrelated with the more common skeletal origin of the majority of chronic pain patients.
No Treatment Pain was not treated in young men, in those with mild pain and in those with pain mainly located in arms and teeth. These data suggest that such people considered their painful events to be such of low importance that they would neglect their treatment. Our data were slightly higher than those observed by Taylor and Morency4 in the general population of the USA, but lower than those reported by Elliott et al.38 in British patients with chronic pain. This may be explained by the helplessness that some patients with chronic pain feel in overcoming their pain which makes them avoid further attempts to treat it. However, there may also be a cultural component to this type of behavior. Some studies in our area addressing the treatment of common health disorders have shown that young men show a trend towards avoiding treatment for such ailments.29 In conclusion, our study shows that pain treatment is a common motivation for patients to seek medical care and for using drugs in Catalonian population. The direct consequence of this finding is that pain should be regarded as one of the most important health problems in Western countries. Additionally, consultation of a physician is often used with other therapies, such as self-medication and complementary medicines and, as a consequence, the economic costs of pain are still higher than calculated only by NHS expenditures. A second finding is that the characteristics of patients using each therapeutic approach differ when considering the type of pain complaint, age or gender. As a consequence, interventions may be targeted not only to specific pain complaints but also to
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Pain Treatment in the General Population
particular populations to improve therapeutic behaviors. Our data may be used to improve the characteristics of pain treatment and to allow a more efficient use of available resources.
Acknowledgments
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9. James FR, Large RG, Bushnell JA, Wells JE. Epidemiology of pain in New Zealand. Pain 1991; 44: 279–283. 10. Anderson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic pain in a geographically defined general population: studies of differences of age, gender, social class and pain localizations. Clin J Pain 1993; 9: 174–182.
This study was supported by a grant contract between the Autonomous University of Barcelona and Química-Farmacéutica Bayer (Spain). The authors would especially like to thank Fèlix Berrocal in obtaining financial resources. The authors also wish to thank Antònia Fernández, Carme García and Carme Castells for their contributions during the telephone interview stage and Montserrat Cañellas, Montserrat Rué, Mercedes Campillo and Pere Escudé for their collaboration in various parts of the study. Uraina Clark and Chuck Simmons helped greatly with the English translation and review of the manuscript. We would also like to mention the Institut d’Estadística de Catalunya for allowing us access to the census figures needed for the study. And, finally, we would like to thank all of the people who kindly gave us their time to participate in the telephone interview.
11. Bassols A, Bosch F, Campillo M, Cañellas M, Baños JE. An epidemiological comparison of pain complaints in the general population of Catalonia (Spain). Pain 1999; 83:9–16.
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