A review of chronic pain impact on patients

[Full text] A review of chronic pain impact on patients, their social environment | Journal of Pain Research | June 2016

Chronic pain (CP) seriously affects the patient’s daily activities and quality of life, but few studies on CP have considered its effects on the patient’s social and family environment

In this work, through a review of the literature, we assessed several aspects of how CP influences the patient’s daily activities and quality of life, as well as its repercussions in the workplace, and on the family and social environment

Finally, the consequences of pain on the health care system are discussed.

On the basis of the results, we concluded that in addition to the serious consequences on the patient’s life, CP has a severe detrimental effect on their social and family environment, as well as on health care services.  

Thus, we want to emphasize on the need to adopt a multidisciplinary approach to treatment so as to obtain more comprehensive improvements for patients in familial and social contexts. Accordingly, it would be beneficial to promote more social- and family-oriented research initiatives.

Introduction

Chronic pain (CP) is recognized as a major public health problem, producing a significant economic and social burden. Moreover, this condition not only affects the patient (both as a sensory and emotional problem) but it also affects his/her family and social circle.

The biopsychosocial model, considered essential in pain, provides a framework for understanding how different diseases are related through an assessment of sensorial, cognitive/affective, and interpersonal factors.

Thus, considering this framework, it has been shown that CP is often associated with other processes that, in turn, affect pain strongly.

bio-psycho-social

Figure 1 Biopsychosocial model of pain and consequences on the quality of life.

The experience of pain interferes with different aspects of the patient’s life, negatively affecting their daily activities, physical and mental health, family and social relationships, and their interactions in the workplace

This problem also affects the health care system and what is known as economic well-being, the strong burden associated with CP not only deriving from health care costs but also from the loss of productivity and from compensatory payments to patients as a result of the disability that pain produces

Despite their relevance, few studies have addressed all these aspects of CP in a comprehensive and multidimensional manner, and studies that specifically analyze the impact of pain on the family environment are scarce

In this review, our goal was to describe the effect of CP on the individual, their family and social environment, as well as on the health care system.

To achieve this, we initially address the consequences of CP on the patient’s daily activities and health-related quality of life (HRQoL), (See Health-Related Quality of Life (HRQOL)) before reviewing the repercussions of CP at the workplace, and in the family and social environment. Finally, we discuss the consequences of CP on the health care system

Results

A total of 78 studies were selected for this review. Of them, 68 met the criteria previously described and were included in the description of the results of this study.

The effects of pain on the patient

Effects on physical function and daily activities

Several studies have analyzed the effect of CP on patient’s lives, highlighting the strong correlation between this condition and reduced physical activity

In fact, the intensity, duration, or location of pain have a decisive influence on a patient’s physical performance, diminishing their physical activity and even causing disability, which in turn affects other aspects of their daily life

In a study carried out on individuals with chronic back pain, the ability to perform daily activities was limited to just under a third of the individuals (31.7%), while elsewhere, physical deterioration was evident in 50% of patients with nononcological pain

In a survey across Europe, most individuals who experienced CP suffered different limitations, with the ability to perform

  • intense physical exercise,
  • walk,
  • perform domestic chores,
  • participate in social activities, and
  • maintain an independent lifestyle

being the activities most affected.

It is important to note that CP patients (as opposed to pain-free individuals) are often unconscious of their level of activity, given that objective and subjective measures of their physical activity differ

This is interesting, since if patients overestimate their level of activity, they might feel it to be sufficient, and thus the intention or motivation to change their behavior and augment their activity would disappear

The intention or motivation to change is one of the key predictors of behavioral modifications according to the theoretical models normally employed.

This is why making patients conscious of their behavior may ensure that they adopt a healthier lifestyle, becoming more active and diminishing the disability caused by their pain.

Effects on health-related quality of life

Several studies carried out on patients with fibromyalgia, rheumatoid arthritis, or low back pain have shown that these conditions often cause a notable deterioration in the patient’s quality of life, each affecting the physical component of the HRQoL and with a stronger impact on the mental component of the HRQoL, particularly in fibromyalgia patients

Similarly, when comparing the HRQoL of acute pain and CP patients with that of pain-free individuals, CP patients achieve worse scores in all the dimensions of HRQoL compared to individuals who suffer from acute pain or have no pain.

Some links between pain intensity and HRQoL have been defined in pain patients, demonstrating that the stronger the intensity of pain the lower the HRQoL

Moreover, patients with severe and frequent pain have a poorer quality of life than patients with moderate and less frequent pain, their pain having a greater impact on the physical dimensions than on the mental ones

When it’s so obvious, does this really need to be stated? Is this actually new knowledge?

Sleep disturbances are commonly experienced by CP patients, and they are closely related to HRQoL

In a prospective study involving a group of women affected by CP, a bidirectional association between sleep and pain was demonstrated, whereby one night of poor sleep was followed by an increase in pain intensity the following day

Likewise, a day of greater pain intensity was followed by a night with sleep disturbances.

Work, social, and family-related consequences of pain

Work-related consequences

Studies carried out in different countries have shown that patients who are affected by pain present problems of absenteeism. Not only must they often change their occupational duties or post, but they may even end up losing their job as a result of their pain symptoms.

when individuals with CP do not take time off from work despite being in pain, there is a reduction in their efficiency and productivity,2,25 an effect that is amplified as the intensity of pain increases

Indeed, it has been demonstrated that such presenteeism reduced productivity by 21.5% in a group of individuals with mild pain, as opposed to the individuals who suffered moderate (26%) and severe pain (42.9%) in whom these percentages were progressively higher

Other studies have also documented that absenteeism, presenteeism, early retirement, and disability related to CP present a burden at least as great as conditions that are conventionally prioritized as public health concerns

This states that pain is NOT conventionally prioritized

When the occupational consequences of different types of pain were analyzed, the processes that produced most days of sick leave are backache, followed by pain caused by rheumatic diseases

These effects on the working environment make it difficult for patients to maintain a normal lifestyle.

In low back pain patients, it has been reported that, specifically in the 45- to 65-year-old age group, low back pain is one of the most frequently cited medical reasons for work loss

Similarly, it has been shown that between 43% and 78% of fibromyalgia patients are in sick leave, and the total disability status ranges between 6.7% and 30%

Another important point between pain and work is the evidence that some of the relatives beliefs and behaviors appeared to pose an obstacle and impede the affected individual from returning to work.

Social and family-related consequences

it has been reported that half of the patients in pain indicated that their condition had prevented them from attending social or family events, and similarly, almost half of the individuals with pain symptoms had less contact with their family

Likewise, a decline in physical capacity and mental health has been observed in patients with neuropathic pain, which contributes strongly to their impaired social integration.

In addition, the negative emotions, irritability, and feelings of anger that often affect these patients have a negative impact on interpersonal relationships and the levels of stress in families.

In a qualitative study carried out on neuropathic pain patients, difficulties in planning social activities in advance due to the unpredictable nature of pain were identified as the main cause of their social limitations

The disability produced by pain and the dependency that it often causes can also have consequences for the family and friends. To be more specific, family members often find that they need to undertake activities, such as care duties, supervision, or participation in and evaluation of treatments, and they must become involved in decision making when consulting doctors

In a recent study, it was observed that a high proportion of the relatives of CP patients suffered anxiety or sadness and that they had stopped taking part in social activities because of the presence of pain in their family

The suffering of a loved one due to pain has also been reported elsewhere to be an overwhelming experience for the family members who look after them, and often the pain or anguish that the patients suffer is felt indirectly, transformed, imagined, or distorted by caregivers, who think it is worse than it really is.

In general, the existence of CP has a negative effect on the family environment, which is perceived more intensely by the relatives than by the patient, especially by family members who are caregiver

However, the perception of sadness in the family, mood swings, and the deterioration in leisure activities, along with sleep disturbances, all as a result of the presence of pain, are factors that both the patient and their relatives identify as having the greatest impact on the family

In this study, the negative factors are blamed on pain, NOT opioids, as in so many other studies.

The consequences of pain on health care systems

There is evidence that pain constitutes an economic burden associated with considerable direct and indirect costs to health care systems and that it is one of the main reasons for medical appointments

in one study, 60% of CP patients reported that they had visited their doctor between two and nine times in the months prior to the study, and 11% had done so at least ten times. In addition, most of the patients (70%) went to their General Practitioner (GP), while 27% (23% in Spain) visited a specialist and only 2% were treated by a pain specialist

A recent study in Portugal reported an average of six medical consultations per year among CP individuals, twice the mean seen in the general Portuguese population, and only a minority of these patients were attended to by a pain specialist.

a greater severity and higher frequency of pain, the presence of comorbidities (physical as well as mental), and the existence of a high level of pain-related limitations and disability are factors that most strongly influence the use of health care resources by these patients

This is written as though the use of health care resources is a “bad thing”. But this is because health care is notoriously ineffective at managing pain. 

If it were possible to get effective treatment for pain (it is, with opioids) perhaps people with pain wouldn’t have to keep going back for more appointments.

It has also been reported that people who leave or lose their job as a result of pain, as well as those who perceive that their pain affects their family, are those that use the health care system the most.

This only makes sense: the more a person’s life is disrupted by pain, the more effort they will make to “fix it”.

Furthermore, a number of studies have demonstrated that pain is often inadequately diagnosed and treated in primary care, with an overuse of medical appointment and health care resources.

Conclusion

CP has significant consequences for patients, as well as for their families, and their social and professional environment, causing deterioration in the quality of life of patients and those close to them

The high prevalence of CP, and its serious medical and nonmedical consequences, means that those responsible for health care policies should pay particular attention to this problem.

Specifically, effective health policies must be developed to prevent and manage pain, minimizing or avoiding the disability that it causes to the patient and its effects on their environment.

Moreover, understanding pain as a public health priority will help to explain its close links with the social and economic aspects of health.

This is the problem: Pain has zero public health priority these days, probably because it’s related to the “opioid crisis” and no one wants to write anything that could be considered pro-opioid. 

All the latest research studies are only about the negative effects of opioids, over and over again, but no one mentions even a word about their effectiveness and lack of danger for 95% of people.

Public health policies are ONLY targeting the negatives of opioid pain relievers, without any efforts to better understand how they are used appropriately for pain management.

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