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Chronic Pain: The Extra Burden on Canadian Women

Chronic Pain: The Extra Burden on Canadian Women Health Issue: Chronic pain is a major health problem associated with significant costs to both afflicted individuals and society as a whole. These costs seem to be disproportionately borne by women, who generally have higher prevalence rates for chronic pain than do men. Key findings: Data obtained from 125,574 respondents to the Canadian Community Health Survey (2000–2001) indicated that 18% of Canadian women suffered from chronic pain, compared to 14% of men. This gender discrepancy, however, seemed to be linked primarily to differences in age, income, and education between adult men and women in this large sample. Age, income, depression and functional interference with activities were strongly associated with chronic pain in general. No gender differences were found in the intensity of pain experienced. Ethnicity was not strongly associated with chronic pain prevalence, although Asians were the group with the highest chronic pain prevalence in the over-65 age group and Aboriginal Canadians had the highest prevalence in the under-65 age group. Data Gaps and Recommendations: Current gaps in our knowledge include the types of chronic pain women experience, their impact on domestic responsibilities and parenting and health care utilization patterns of women with chronic pain. Data sources such as provincial databases of billing claims may be useful in the future to enrich our knowledge of health care utilization and analgesic medication use. Enhanced surveillance, assessment, and early identification of pain disorders are recommended to improve outcomes. Considering current demographic patterns toward an older population, there is also some urgency to the development of patient education and self-management programs. Background ally defined as any continuous or persistent intermittent Chronic pain is a major public health problem that places pain experienced for a period longer than three serious stress on afflicted individuals, the health care sys- months,[1] chronic pain affects individuals of all ages and tem and private industry. It has been associated with def- ethnic backgrounds as well as both sexes. However, epide- icits in quality of life and psychological adjustment, miologic, clinical and experimental studies have all disability, reduced income potential, high levels of health consistently found that the burden of pain is greater for care utilization and high costs to private industry. Gener- women than for men. Page 1 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 The magnitude of the sex difference in pain[2,3] is diffi- therefore, chronic pain is also associated with multiple cult to determine, as it varies, depending on the type of comorbid conditions.[9] As well, some studies have con- pain and the population being studied. Recent reviews, sistently found an association between chronic pain and however, report that the prevalence of most pain condi- lower educational levels and socio-economic sta- tions is higher among women than men.[4,5] Identifying tus.[12,13,16] Psychological distress is common in both the sources of this difference in pain is a complex matter men and women who experience chronic pain, depres- that requires a bio-psychosocial perspective. sion being a common, strong correlate.[7,17] Estimates of depression prevalence among patients with chronic pain In terms of biological factors, the transmission and mod- range from 31% to 100%,[18] and pain complaints in ulation of pain signals may differ in men and depressed individuals range from 34% to 66%.[19] This is women.[5,6] Normal hormonal variations and changes particularly a concern for women, as they suffer from clin- related to women's reproductive functions can be sex-spe- ical depression at twice the rate of men. cific sources of pain, as can pathologic processes associ- ated with these.[7] Psychologically, women may differ in The functional interference of pain is also high, and a their cognitive and emotional processing of pain and also whole range of activities are often severely curtailed. Daily behave differently when in pain.[4] Socially, women dif- chores become difficult, ability to work diminishes, and fer from men in their societal, family and occupational there is a lower rate of full-time employment. [10-12] roles (e.g. multiple primary-role responsibilities), and Social support can also diminish as friends and family these may also be potential sources of sex differences in lose patience with a problem that is usually invisible and pain. endless.[20] Individuals with chronic pain can also suffer rejection from health care providers frustrated with their Patterns of Pain Prevalence in Canada failed attempts to heal and with the dependence on pain In a random survey of 500 households in Ontario, preva- medications that their patients commonly show.[11] lence rates of chronic pain were found to be 11% among people under 60 years and 25% to 40% for those over Societal Factors Associated with Chronic Pain 60.[8] The 1994–1995 NPHS indicated that 17% of the In addition to the burden on the individual, chronic pain also exacts a high cost from society at large and the health total population aged 15 and over experienced chronic pain. The prevalence was higher among women than men care system in particular. It is associated with a loss of pro- (20% versus 16%) and increased with age.[9] The most ductivity, high utilization of health services and substan- common chronic pain conditions were back pain and tial health care expenditures. Women in North America arthritis/rheumatism. A survey of 410 adults in the have a higher rate of health care utilization than men,[21] Edmonton area found a prevalence rate of 44%, the most and this may be, in part, attributable to their higher rates common pain locations being the back, head and neck. of pain complaints. Direct medical costs for outpatient Overall, the prevalence was, again, higher among women visits related to chronic pelvic pain alone have been esti- (65.5% versus 34.5%) but, in this sample, was unrelated mated at $881.5 million per year in the United States. to age.[10] Among 548 employed respondents in one study, 15% reported time lost from paid work and 45% reported Recent chronic pain prevalence rates in other Western reduced work productivity.[11] The economic cost of countries are comparable to those found in Canada. U.S. chronic pain to society is very difficult to calculate as it estimates have placed the prevalence rates among women involves various sectors, both public and private. How- in the United States at 14.7% in the 18 to 50 age ever, judging from the high prevalence rates, high health range.[11] An Australian survey reported a rate among care utilization by this population, absenteeism, disabil- women of 20% in comparison with 17% among men.[12] ity, high levels of medication dependence, and the failure In Europe, a Swedish survey found that 23.9% of its sam- of multiple and frequent expensive medical procedures, ple reported chronic regional pain.[13] In a population- the economic costs are undoubtedly astronomical. based study in Scotland involving 4,611 individuals aged 25 and over, the prevalence rate of "significant chronic Pain, which may be a disorder in itself rather than simply pain" was 14.1% and was higher among women and a symptom of an underlying condition, is increasingly rec- older age groups.[14] ognized as a substantial public health problem. More comprehensive and gender-sensitive information on pain Individual Factors Associated with Chronic Pain is needed in Canada so that enhanced interventions can Age and socio-economic variables have been associated be developed. In this chapter, the overall burden of with chronic pain. For certain pain syndromes, such as chronic pain among Canadian women as well as its deter- joint pain, chronic widespread pain and fibromyalgia, minants and impact are assessed using currently available prevalence rates increase with age.[15] Not surprisingly, population health data. Page 2 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Methods Data obtained from the Canadian Community Health Survey (CCHS) Cycle 1.1 (2000–2001) were used in this chapter. This survey was cross-sectional in design and had a total of 131,535 respondents. Health Canada had access to data on the 95.5% (125,574) of these respondents who agreed to share their information. All analyses presented in this chapter used the sample of respondents who agreed to share their information. The prevalence and intensity of chronic pain were compared between men and women and among subgroups of women. Chronic pain status was determined by participants' response to the question "Are you usually free from pain or discom- Chroni Figure 1 c Pain Prevalence by Age, Sex and Intensity, Canada fort?" Those who answered "no" were considered to have Chronic Pain Prevalence by Age, Sex and Intensity, chronic pain. The estimated prevalences were calculated Canada. Source: Statistics Canada, CCHS, 2000–2001 using a weighted method to account for the complex sam- pling design of the survey. The relative contributions of physical/medical (presence of chronic condition(s), etc.) and socio-economic factors to the sex and gender differ- ences were examined using bivariate and multivariate (logistic regression) analysis. Correlates of chronic pain, including depression, restric- tions in daily activity, health care utilization and medica- tion use, were also examined and compared between men and women and subgroups of women. Statistics Canada's Bootstrap program was used to deter- mine statistically significant differences between preva- lence rates for all confidence intervals (CI) reported for the difference between females and males. Results Prevalence of Selected Chro With Figure 2 Chronic Pain, by Sex, Canada nic Conditions Among Those Prevalence of Chronic Pain Prevalence of Selected Chronic Conditions Among According to data collected from Cycle 1.1 (2000–2001) Those With Chronic Pain, by Sex, Canada. Source: of the CCHS, 16% of the population 12 years of age and Statistics Canada, CCHS, 2000–2001 older suffered from chronic pain (14% males versus 18% females, 95% CI 3.73, 4.99). Classification of pain as either mild, moderate or severe was proportionally similar in males and females (Figure 1). Although many conditions can result in chronic pain, the Individual Factors Associated with Chronic Pain survey asked specifically about four conditions known to be strongly related to chronic pain. Among those with The prevalence of chronic pain increased with age in both chronic pain in this study, the prevalence of arthritis/rheu- sexes (Figure 3). The prevalence was higher among matism (95% CI 9.29, 12.97), fibromyalgia (95% CI 5.51, females than males at all ages. There was also a clear asso- 7.06) and migraine headaches (95% CI 9.76, 12.68) is sig- ciation between household income and chronic pain (Fig- nificantly higher among women than men (Figure 2). ure 4). The prevalence of chronic pain was lower among There is a slight difference in the prevalence of back pain those in higher income categories and higher for those in (95% CI 0.20, 4.27) among those who report chronic lower income categories. pain (excluding fibromyalgia and arthritis). Although the difference in back pain is statistically significant, the prac- Marital status appeared to be associated with chronic tical implication of this difference warrants further inves- pain. In both sexes and for all ages, chronic pain tigation. The prevalence of fibromyalgia is low among prevalence was lowest among those who were single (Fig- those who report chronic pain (Figure 2). ure 5) and, except among males less than 65 years, highest Page 3 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Preval Figure 3 ence of Chronic Pain by Age and Sex, Canada Prevalence of Chr Canada Figure 5 onic Pain by Sex, Age and Marital Status, Prevalence of Chronic Pain by Age and Sex, Canada Prevalence of Chronic Pain by Sex, Age and Marital Source: Statistics Canada, CCHS, 2000–2001 Status, Canada. Source: Statistics Canada, CCHS, 2000– Chronic Pain Prevale Figure 4 nce by Household Income, Canada Di Chronic Pa Figure 6 stribution of in, by Ag Chronic Co e and Sex, nditions Canada Among Those With Chronic Pain Prevalence by Household Income, Can- Distribution of Chronic Conditions Among Those ada. Source: Statistics Canada, CCHS, 2000–2001 With Chronic Pain, by Age and Sex, Canada. Source: Statistics Canada, CCHS, 2000–2001 in those who were divorced or separated. There were no differences in chronic pain prevalence by family structure. A high body mass index (BMI) has been found to be asso- ciated with increased mortality and decreased life expect- Across age and sex, the majority of those with chronic ancy. Comparison of chronic pain prevalence across BMI pain had three or more chronic conditions, whose preva- also revealed an association: the prevalence was higher for lence increased with age for both sexes (Figure 6). each subsequent BMI category among females, with the lowest prevalence among those who had a BMI of less Pain intensity was similar for males and females (Figure than 20 and the highest among those with a BMI of 7). Proportionally, this study found that the level of pain greater than 27 (Figure 8). Among males, the prevalence intensity among those who suffered from chronic condi- of chronic pain was similar in all BMI categories. Female tions associated with pain (back pain, fibromyalgia, chronic pain prevalence was significantly higher than that arthritis/rheumatism and migraine headaches) was of males in the "some excess weight" and "overweight" similar to the level among those suffering from other categories (95% CI 3.41, 7.21 and 7.14, 9.92 types of chronic pain. respectively). Page 4 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Pain Intensity Among Th Condi Figure 7 tions, Canada ose With Pain-Associated Chronic Preval Sex, Ca Figure 9 ence of nada Depression by Chronic Pain Status, Age and Pain Intensity Among Those With Pain-Associated Prevalence of Depression by Chronic Pain Status, Chronic Conditions, Canada. Source: Statistics Canada, Age and Sex, Canada. Source: Statistics Canada, CCHS, CCHS, 2000–2001 2000–2001 Chr Figure 8 onic Pain Prevalence by Sex and BMI, Canada Preval Canada Figure 10 ence of Depression by Pain Intensity, Age and Sex, Chronic Pain Prevalence by Sex and BMI, Canada. Prevalence of Depression by Pain Intensity, Age and Source: Statistics Canada, CCHS, 2000–2001 Sex, Canada Source: Statistics Canada, CCHS, 2000–2001 The prevalence of depression was twice the rate among direct result of their pain. The percentage of females who those who reported chronic pain as among those who did were limited in a few or more activities was higher than not and appeared to be related to age for both males and the percentage observed among males (77.7% versus females (Figure 9). The prevalence of depression was 70.7%). almost twice as high among individuals with chronic pain who were aged less than 65 years as among those 65 years Comparing individuals with chronic pain to those with- and older for both males and females (Figure 9). out revealed that the proportion requiring help with at least one task was substantially higher among those suf- Depression was also related to pain intensity for both fering from chronic pain than those who were free from sexes. Figure 10 shows that a higher level of pain intensity pain (Figure 11). was associated with a higher prevalence of depression. For those who suffered from chronic pain, employment Chronic pain affects daily tasks and can cause restrictions issues were very important. In this sample, it was found in daily activities. In both age categories (less than 65, and that the majority of those who were unable to work in the 65 and older) the majority of those who suffered from week before being interviewed suffered from pain (Figure chronic pain were limited in at least "a few" activities as a 12). Chronic pain also appeared to be associated with Page 5 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Proportion Requiring Help by Chronic Pain Ag Figure 11 e, Canada Status, Sex and Preval Figure 13 ence of Chronic Pain by Self-Rated Health, Canada Proportion Requiring Help by Chronic Pain Status, Prevalence of Chronic Pain by Self-Rated Health, Sex and Age, Canada Source: Statistics Canada, CCHS, Canada. Source: Statistics Canada, CCHS, 2000–2001 2000–2001 Preval Figure 14 ence of Chronic Pain by Self-Rated Stress, Canada Preval Figure 12 ence of Chronic Pain by Employment Variables Prevalence of Chronic Pain by Self-Rated Stress, Prevalence of Chronic Pain by Employment Varia- Canada. Source: Statistics Canada, CCHS, 2000–2001 bles Source: Statistics Canada, CCHS, 2000–2001 type of occupation, the prevalence being lowest among chronic pain and those with lower levels of stress had a professionals and highest in occupations in lower prevalence of chronic pain (Figure 14). manufacturing and natural resources. The association between type of occupation and prevalence of chronic In this analysis, social support was measured by a variable pain was similar among males and females. referred to as "tangible social support," which measures whether the individual had somebody to take them to the Poor self-rated health was inversely related to chronic doctor, do their chores, prepare meals or help if they were pain (Figure 13). Those who ranked their health as excel- confined to a bed. lent had the lowest prevalence of chronic pain, and the prevalence was highest among those who felt that their Figure 15 shows that there was a negative association health was poor. This trend was similar in both males and between chronic pain and perceived social support. Pain females. was reported more frequently by those who received less social support. This was true for males and females and Self-rated stress was related to chronic pain, in that those indicates that perceived social support is an important fac- who were extremely stressed had the highest prevalence of tor to consider in those with chronic pain. Page 6 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Societal Factors Associated with Chronic Pain Chronic pain sufferers have a substantial impact on the use of health care services. As shown in Figure 18, compar- isons for all selected indicators of health care utilization showed that use was higher among those who reported suffering from chronic pain than those who did not. Use of chiropractors, physiotherapists and alternative health care providers was lower among those 65 years and older. Medication use was higher among those reporting chronic pain than those not doing so for all medications in gen- eral and all selected types of medication (Figure 19). The use of pain medications such as pain relievers, Preva Canada Figure 15 lence of Chronic Pain by Perceived Tangible Support, tranquilizers, antidepressants and opiates was two to four Prevalence of Chronic Pain by Perceived Tangible times as high in those with chronic pain than in those Support, Canada Source: Statistics Canada, CCHS, 2000– without chronic pain. Discussion Characteristics of Chronic Pain Sufferers The chronic pain sufferer in Canada is more likely to be a woman than a man, although the gender difference is not tied exclusively to sex. Women also have lower incomes, less formal education and twice the prevalence of depres- sion, all of which were strongly associated with the report of chronic pain in this study. It thus seems reasonable to speculate that the differences in chronic pain evidenced in this CCHS were attributable to a combination of biologi- cal and psychosocial conditions specific to each sex. Not Percentage E Figure 16 thnicity of Those With Chronic Pain, by Sex, Age, surprisingly, chronic pain was also strongly associated Percentage of Those With Chronic Pain, by Sex, Age, Ethnicity Source: Statistics Canada, CCHS, 2000– with age and multiple chronic conditions. Women with chronic pain were more likely to report fibromyalgia, arthritis and migraine headaches, although there was no significant sex difference in the prevalence of back pain. In terms of potential impact, chronic pain was strongly related to reports of poor health, high levels of stress, low There do not seem to be major ethnic differences in levels of social support, more functional interference with chronic pain prevalence, with the notable exception of work and other activities, higher levels of dependence on two ethnic groups. For both sexes, in the age group 65 others, higher levels of health care utilization, and higher years and older the proportion of South Asians who medication usage. reported chronic pain was greater than for any other ethnic group. Chinese males and females had the lowest Treatment Approach rates for this age group. Among those aged less than 65 The "chronic" in chronic pain encapsulates the sense of years, Aboriginals had the greatest proportion of reported defeatism that characterizes the common attitude of many chronic pain, for both sexes (Figure 16). patients and health care providers who are dealing with this perplexing and debilitating problem. The etiology of In bivariate analysis, level of education was not associated most chronic pain syndromes remains largely unknown with chronic pain for either of the sexes or age groups. and, consequently, treatment efforts have consisted of pain management, at best, and narcotic dependence, at Figure 17 is a summary table of a multivariate logistic worst. Pain is a multi-dimensional problem not amenable regression model. The results of the regression show that to single causal pathway explanations or treatment when age, chronic conditions associated with pain, other approaches. It involves biological processes as well as cog- chronic conditions, income and education were nitive, emotional and social ones. Chronic pain thus controlled for, females did not have an increased risk of presents a challenge to both health care providers and chronic pain as compared with males. patients understandably searching for a quick and defini- tive solution. Page 7 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 L Figure 17 ogistic Regression of Variables Associated With Pain, Odds Ratios Logistic Regression of Variables Associated With Pain, Odds Ratios Source: Statistics Canada, CCHS, 2000–2001. Statistics Canada bootstrap programs used P Figure 18 ercentage Health Care Utilization in The Previous 12 Months, by Chronic Pain Status and Age Percentage Health Care Utilization in The Previous 12 Months, by Chronic Pain Status and Age. Source: Statis- tics Canada, CCHS, 2000–2001 Page 8 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Medica Figure 19 tion Use in Previous Month by Chronic Pain Status and Age Medication Use in Previous Month by Chronic Pain Status and Age. Source: Statistics Canada, CCHS, 2000–2001 Multidisciplinary treatment is indicated for multi-dimen- Data Limitations sional problems such as chronic pain. In addition to med- The data source for the analysis in this chapter was cross- ical and physical therapy, cognitive-behavioural sectional in nature, and as a result causal pathways are dif- approaches have been shown to be important compo- ficult to infer. Also, since the survey was based on nents in treatment. Recent research indicates that behav- respondents' self-reports, the quality and accuracy of the ioural interventions are generally superior to medical data cannot be determined. Furthermore, the survey asked treatment controls in improving pain, decreasing respondents about only four specific chronic conditions disability and increasing activity levels.[22] These inter- that have been associated with chronic pain. Clearly, there ventions can also have the effect of teaching patients skills are many other conditions that can result in chronic pain. for continued self-care.[23] Gaps and Recommendations Implications for Health Care Utilization There are a number of gaps in the chronic pain and gender Despite the demonstrated effectiveness of multidiscipli- data currently available. One major gap is the lack of nary approaches to the treatment of chronic pain, it is detailed data on the types of chronic pain that women only a highly select group of patients who ever reach experience. Chronic pelvic pain is an example of a gender- multidisciplinary pain clinics. Most chronic pain patients specific pain tied to women's reproductive function for show a pattern of repeated consultations with primary which there is little Canadian, population-based data, care doctors and high levels of multiple consultations in despite ample U.S. evidence indicating that this is a major the hopes of finding the one who will solve the problem. women's health care problem. Endometriosis and This high level of consultation is sometimes also fuelled polycystic ovarian disease are just two of the common dis- by the search for more prescription analgesics, after the orders of reproductive function that result in chronic pel- tolerance of prior health care providers has been vic pain, although much of this pain is without obvious exhausted. The continuity of care becomes a major pathology. Vulvar vestibulitis and vulvodynia are also problem as patients skip from one provider to another. increasingly reported in both pre- and post-menopausal The elusive treatment is never found, drug dependence is women. Temporomandibular joint disorder (TMJ) is yet common, and the consequent expense is a major burden another example of a chronic pain disorder that affects on the Canadian health care system. predominantly women. Although specialty pain clinics are often perceived as A second major gap in the Canadian literature is system- expensive ventures, their treatment outcomes can result in atic data collection from sources other than self-reports. lower levels of patient disability. They are thus likely to Provincial databases of billing claims need to be investi- have an impact on health care utilization.[24] The gated to obtain a clearer picture of health care utilization, economics of health care may be such that high front-end prevalence of pain disorders and pain disorder-related investments may result in long-term health care savings patterns of analgesic medication prescription. The Phar- for the system as a whole. macare data from some provinces could be useful in Page 9 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 inferring the presence of chronic pain syndromes, as the efficient way to teach patients self-management strategies prevalence of heavy users of analgesic drugs could be that have been empirically shown to lead to significant detected using this source. In addition, many women decreases in pain, disability and medical consulta- report reproductive function-related pains to obstetricians tions.[23] As well, women have been shown to be more or gynecologists who often serve as their primary care amenable to this type of self-care than men. providers. Studies on women's health care need to increase the focus on this group of providers in addition Multidisciplinary pain clinics have demonstrated effec- to the existing focus on primary care doctors. Billing data- tiveness and may, in the long term, be the most bases may also serve to clarify the currently murky picture economical and effective recourse in the treatment of regarding chronic pain prevalence in different ethnic chronic pain. Rather than envision these as clinics within groups. Cultural differences in the acceptability of large, central metropolitan hospitals, perhaps smaller reporting pain may be obscuring ethnic trends that could community-based versions would better serve the popula- be directly targeted by public health efforts. tion in question. These smaller clinics would be more accessible to women who may be older, be disabled, or A third gap of particular importance to women is the lack have lower income and/or have children, and they could of assessment of the functional impact of chronic pain on also be tailored to the culturally specific characteristics of domestic responsibilities and parenting. The CCHS and the community. many other surveys have consistently shown a connection between reports of chronic pain and employment interfer- Conclusion ence, but there is very little investigation into the impact Chronic pain is a daunting problem for both individuals of pain on work in the home. This kind of functional and society. Its effects on quality of life and economic impairment gets lost in the employment data. If chronic costs demand attention as we enter the twenty-first pain is interfering with work outside the home, it is most century and plan for improvements in the delivery of likely also interfering with work inside the home. The lack health care to Canadians. The current age structure of the of assessment of this type of interference only serves to Canadian population indicates a large expected increase marginalize an important aspect of women's lives and in the number of individuals who are over the age of 65 hide the wide-ranging deleterious effect of chronic pain over the next 30 years. This necessarily means an increase on women and their families. in the prevalence of chronic pain, especially among women. Strategies for addressing this growing problem Filling these gaps in our knowledge about women and are needed to reduce the overall impact of chronic pain. pain is likely to prove integral to the development of The collection of more finely gradated information on the strategies designed to reduce the impact of chronic pain. nature and impact of chronic pain and health care utiliza- Certain recommendations, however, can already be sug- tion is necessary, yet health care delivery strategies cannot gested. Surveillance and early identification of pain wait for all of the information to be collected. The aim of disorders is crucial, as there are both theoretical and this survey and report is to make a contribution to future empirical reasons to believe that early treatment will data collection efforts and to ongoing and future result in better outcomes. Untreated pain can establish a applications centred on the care of both men and women central nervous system hold that becomes increasingly suffering from chronic pain. resistant to peripheral and other interventions. Long- standing pain can also result in behaviour patterns (e.g. References 1. Merskey H, Bogduk N: Classification of chronic pain 2nd edition. Seattle: lack of activity) that lead to other complicating disorders IASP Press; 1994. (e.g. obesity) and to cognitive and emotional problems 2. Fillingim RB: Sex, gender and pain: a biopsychosocial frame- (e.g. depression) that complicate treatment. Finally, the work. In: Sex, gender and pain Edited by: Fillingim RB. Seattle: IASP Press; 2000:1-6. more long-standing the pain, the more likely is the 3. Leresche L: Chronic pain. In: Behavioral medicine and women Edited dependence on narcotics and other pain medications. by: Blechman EA, Brownell KD. New York: The Guilford Press; 1998:788-792. 4. Unruh AM: Gender variations in clinical pain experience. Pain Primary care providers and obstetrician/gynecologists are 1996, 65:123-167. crucial to this surveillance and early detection effort. 5. Berkley KJ: Sex differences in pain. Behav Brain Sci 1997, 20:371-380. Assessment of pain needs to be incorporated into the first 6. Gear RW, Miaskowski C, Gordon NC, et al.: Kappa-opioids pro- consultation and targeted, even if it is not the primary rea- duce significantly greater analgesia in women than in men. son for the consultation. It then needs to be reassessed Nat Med 1996, 2:1248-1250. 7. Meana M: The meeting of pain and depression: comorbidity in periodically. Patient education about chronic pain syn- women. Can J Psychiatry 1998, 43(9):893-899. dromes is also important, as it can establish hopeful yet 8. Crook J, Rideout E, Browne G: The prevalence of pain com- plaints in a general population. Pain 1984, 18:299-316. realistic expectations and moderate the impulse to consult 9. Millar WJ: Chronic pain. Health Rep 1996, 7(4):47-53. multiple doctors in search of "the cure." It can also be an Page 10 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 10. Birse TM, Lander J: Prevalence of chronic pain. Can J Public Health 1998, 89(2):129-131. 11. Mathias SD, Kuppermann M, Liberman RF, et al.: Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996, 87:321-327. 12. Blyth FM, March LM, Brnabic AJ, et al.: Chronic pain in Australia: a prevalence study. Pain 2001, 89(2–3):127-134. 13. Bergman S, Herrstrom P, Hogstrom K, et al.: Chronic muscu- loskeletal pain, prevalence rates and sociodemographic associations in a Swedish population study. J Rheumatol 2001, 28(6):1369-1377. 14. Smith BH, Elliott AM, Chambers WA, et al.: The impact of chronic pain in the community. Fam Pract 2001, 18(3):292-299. 15. 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Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 11 of 11 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Women s Health Springer Journals

Chronic Pain: The Extra Burden on Canadian Women

Meana, Marta; Cho, Robert; DesMeules, Marie
BMC Women s Health , Volume 4 (Suppl 1) – Aug 25, 2004
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Copyright © Meana et al; licensee BioMed Central Ltd 2004. This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Health Issue: Chronic pain is a major health problem associated with significant costs to both afflicted individuals and society as a whole. These costs seem to be disproportionately borne by women, who generally have higher prevalence rates for chronic pain than do men. Key findings: Data obtained from 125,574 respondents to the Canadian Community Health Survey (2000–2001) indicated that 18% of Canadian women suffered from chronic pain, compared to 14% of men. This gender discrepancy, however, seemed to be linked primarily to differences in age, income, and education between adult men and women in this large sample. Age, income, depression and functional interference with activities were strongly associated with chronic pain in general. No gender differences were found in the intensity of pain experienced. Ethnicity was not strongly associated with chronic pain prevalence, although Asians were the group with the highest chronic pain prevalence in the over-65 age group and Aboriginal Canadians had the highest prevalence in the under-65 age group. Data Gaps and Recommendations: Current gaps in our knowledge include the types of chronic pain women experience, their impact on domestic responsibilities and parenting and health care utilization patterns of women with chronic pain. Data sources such as provincial databases of billing claims may be useful in the future to enrich our knowledge of health care utilization and analgesic medication use. Enhanced surveillance, assessment, and early identification of pain disorders are recommended to improve outcomes. Considering current demographic patterns toward an older population, there is also some urgency to the development of patient education and self-management programs. Background ally defined as any continuous or persistent intermittent Chronic pain is a major public health problem that places pain experienced for a period longer than three serious stress on afflicted individuals, the health care sys- months,[1] chronic pain affects individuals of all ages and tem and private industry. It has been associated with def- ethnic backgrounds as well as both sexes. However, epide- icits in quality of life and psychological adjustment, miologic, clinical and experimental studies have all disability, reduced income potential, high levels of health consistently found that the burden of pain is greater for care utilization and high costs to private industry. Gener- women than for men. Page 1 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 The magnitude of the sex difference in pain[2,3] is diffi- therefore, chronic pain is also associated with multiple cult to determine, as it varies, depending on the type of comorbid conditions.[9] As well, some studies have con- pain and the population being studied. Recent reviews, sistently found an association between chronic pain and however, report that the prevalence of most pain condi- lower educational levels and socio-economic sta- tions is higher among women than men.[4,5] Identifying tus.[12,13,16] Psychological distress is common in both the sources of this difference in pain is a complex matter men and women who experience chronic pain, depres- that requires a bio-psychosocial perspective. sion being a common, strong correlate.[7,17] Estimates of depression prevalence among patients with chronic pain In terms of biological factors, the transmission and mod- range from 31% to 100%,[18] and pain complaints in ulation of pain signals may differ in men and depressed individuals range from 34% to 66%.[19] This is women.[5,6] Normal hormonal variations and changes particularly a concern for women, as they suffer from clin- related to women's reproductive functions can be sex-spe- ical depression at twice the rate of men. cific sources of pain, as can pathologic processes associ- ated with these.[7] Psychologically, women may differ in The functional interference of pain is also high, and a their cognitive and emotional processing of pain and also whole range of activities are often severely curtailed. Daily behave differently when in pain.[4] Socially, women dif- chores become difficult, ability to work diminishes, and fer from men in their societal, family and occupational there is a lower rate of full-time employment. [10-12] roles (e.g. multiple primary-role responsibilities), and Social support can also diminish as friends and family these may also be potential sources of sex differences in lose patience with a problem that is usually invisible and pain. endless.[20] Individuals with chronic pain can also suffer rejection from health care providers frustrated with their Patterns of Pain Prevalence in Canada failed attempts to heal and with the dependence on pain In a random survey of 500 households in Ontario, preva- medications that their patients commonly show.[11] lence rates of chronic pain were found to be 11% among people under 60 years and 25% to 40% for those over Societal Factors Associated with Chronic Pain 60.[8] The 1994–1995 NPHS indicated that 17% of the In addition to the burden on the individual, chronic pain also exacts a high cost from society at large and the health total population aged 15 and over experienced chronic pain. The prevalence was higher among women than men care system in particular. It is associated with a loss of pro- (20% versus 16%) and increased with age.[9] The most ductivity, high utilization of health services and substan- common chronic pain conditions were back pain and tial health care expenditures. Women in North America arthritis/rheumatism. A survey of 410 adults in the have a higher rate of health care utilization than men,[21] Edmonton area found a prevalence rate of 44%, the most and this may be, in part, attributable to their higher rates common pain locations being the back, head and neck. of pain complaints. Direct medical costs for outpatient Overall, the prevalence was, again, higher among women visits related to chronic pelvic pain alone have been esti- (65.5% versus 34.5%) but, in this sample, was unrelated mated at $881.5 million per year in the United States. to age.[10] Among 548 employed respondents in one study, 15% reported time lost from paid work and 45% reported Recent chronic pain prevalence rates in other Western reduced work productivity.[11] The economic cost of countries are comparable to those found in Canada. U.S. chronic pain to society is very difficult to calculate as it estimates have placed the prevalence rates among women involves various sectors, both public and private. How- in the United States at 14.7% in the 18 to 50 age ever, judging from the high prevalence rates, high health range.[11] An Australian survey reported a rate among care utilization by this population, absenteeism, disabil- women of 20% in comparison with 17% among men.[12] ity, high levels of medication dependence, and the failure In Europe, a Swedish survey found that 23.9% of its sam- of multiple and frequent expensive medical procedures, ple reported chronic regional pain.[13] In a population- the economic costs are undoubtedly astronomical. based study in Scotland involving 4,611 individuals aged 25 and over, the prevalence rate of "significant chronic Pain, which may be a disorder in itself rather than simply pain" was 14.1% and was higher among women and a symptom of an underlying condition, is increasingly rec- older age groups.[14] ognized as a substantial public health problem. More comprehensive and gender-sensitive information on pain Individual Factors Associated with Chronic Pain is needed in Canada so that enhanced interventions can Age and socio-economic variables have been associated be developed. In this chapter, the overall burden of with chronic pain. For certain pain syndromes, such as chronic pain among Canadian women as well as its deter- joint pain, chronic widespread pain and fibromyalgia, minants and impact are assessed using currently available prevalence rates increase with age.[15] Not surprisingly, population health data. Page 2 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Methods Data obtained from the Canadian Community Health Survey (CCHS) Cycle 1.1 (2000–2001) were used in this chapter. This survey was cross-sectional in design and had a total of 131,535 respondents. Health Canada had access to data on the 95.5% (125,574) of these respondents who agreed to share their information. All analyses presented in this chapter used the sample of respondents who agreed to share their information. The prevalence and intensity of chronic pain were compared between men and women and among subgroups of women. Chronic pain status was determined by participants' response to the question "Are you usually free from pain or discom- Chroni Figure 1 c Pain Prevalence by Age, Sex and Intensity, Canada fort?" Those who answered "no" were considered to have Chronic Pain Prevalence by Age, Sex and Intensity, chronic pain. The estimated prevalences were calculated Canada. Source: Statistics Canada, CCHS, 2000–2001 using a weighted method to account for the complex sam- pling design of the survey. The relative contributions of physical/medical (presence of chronic condition(s), etc.) and socio-economic factors to the sex and gender differ- ences were examined using bivariate and multivariate (logistic regression) analysis. Correlates of chronic pain, including depression, restric- tions in daily activity, health care utilization and medica- tion use, were also examined and compared between men and women and subgroups of women. Statistics Canada's Bootstrap program was used to deter- mine statistically significant differences between preva- lence rates for all confidence intervals (CI) reported for the difference between females and males. Results Prevalence of Selected Chro With Figure 2 Chronic Pain, by Sex, Canada nic Conditions Among Those Prevalence of Chronic Pain Prevalence of Selected Chronic Conditions Among According to data collected from Cycle 1.1 (2000–2001) Those With Chronic Pain, by Sex, Canada. Source: of the CCHS, 16% of the population 12 years of age and Statistics Canada, CCHS, 2000–2001 older suffered from chronic pain (14% males versus 18% females, 95% CI 3.73, 4.99). Classification of pain as either mild, moderate or severe was proportionally similar in males and females (Figure 1). Although many conditions can result in chronic pain, the Individual Factors Associated with Chronic Pain survey asked specifically about four conditions known to be strongly related to chronic pain. Among those with The prevalence of chronic pain increased with age in both chronic pain in this study, the prevalence of arthritis/rheu- sexes (Figure 3). The prevalence was higher among matism (95% CI 9.29, 12.97), fibromyalgia (95% CI 5.51, females than males at all ages. There was also a clear asso- 7.06) and migraine headaches (95% CI 9.76, 12.68) is sig- ciation between household income and chronic pain (Fig- nificantly higher among women than men (Figure 2). ure 4). The prevalence of chronic pain was lower among There is a slight difference in the prevalence of back pain those in higher income categories and higher for those in (95% CI 0.20, 4.27) among those who report chronic lower income categories. pain (excluding fibromyalgia and arthritis). Although the difference in back pain is statistically significant, the prac- Marital status appeared to be associated with chronic tical implication of this difference warrants further inves- pain. In both sexes and for all ages, chronic pain tigation. The prevalence of fibromyalgia is low among prevalence was lowest among those who were single (Fig- those who report chronic pain (Figure 2). ure 5) and, except among males less than 65 years, highest Page 3 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Preval Figure 3 ence of Chronic Pain by Age and Sex, Canada Prevalence of Chr Canada Figure 5 onic Pain by Sex, Age and Marital Status, Prevalence of Chronic Pain by Age and Sex, Canada Prevalence of Chronic Pain by Sex, Age and Marital Source: Statistics Canada, CCHS, 2000–2001 Status, Canada. Source: Statistics Canada, CCHS, 2000– Chronic Pain Prevale Figure 4 nce by Household Income, Canada Di Chronic Pa Figure 6 stribution of in, by Ag Chronic Co e and Sex, nditions Canada Among Those With Chronic Pain Prevalence by Household Income, Can- Distribution of Chronic Conditions Among Those ada. Source: Statistics Canada, CCHS, 2000–2001 With Chronic Pain, by Age and Sex, Canada. Source: Statistics Canada, CCHS, 2000–2001 in those who were divorced or separated. There were no differences in chronic pain prevalence by family structure. A high body mass index (BMI) has been found to be asso- ciated with increased mortality and decreased life expect- Across age and sex, the majority of those with chronic ancy. Comparison of chronic pain prevalence across BMI pain had three or more chronic conditions, whose preva- also revealed an association: the prevalence was higher for lence increased with age for both sexes (Figure 6). each subsequent BMI category among females, with the lowest prevalence among those who had a BMI of less Pain intensity was similar for males and females (Figure than 20 and the highest among those with a BMI of 7). Proportionally, this study found that the level of pain greater than 27 (Figure 8). Among males, the prevalence intensity among those who suffered from chronic condi- of chronic pain was similar in all BMI categories. Female tions associated with pain (back pain, fibromyalgia, chronic pain prevalence was significantly higher than that arthritis/rheumatism and migraine headaches) was of males in the "some excess weight" and "overweight" similar to the level among those suffering from other categories (95% CI 3.41, 7.21 and 7.14, 9.92 types of chronic pain. respectively). Page 4 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Pain Intensity Among Th Condi Figure 7 tions, Canada ose With Pain-Associated Chronic Preval Sex, Ca Figure 9 ence of nada Depression by Chronic Pain Status, Age and Pain Intensity Among Those With Pain-Associated Prevalence of Depression by Chronic Pain Status, Chronic Conditions, Canada. Source: Statistics Canada, Age and Sex, Canada. Source: Statistics Canada, CCHS, CCHS, 2000–2001 2000–2001 Chr Figure 8 onic Pain Prevalence by Sex and BMI, Canada Preval Canada Figure 10 ence of Depression by Pain Intensity, Age and Sex, Chronic Pain Prevalence by Sex and BMI, Canada. Prevalence of Depression by Pain Intensity, Age and Source: Statistics Canada, CCHS, 2000–2001 Sex, Canada Source: Statistics Canada, CCHS, 2000–2001 The prevalence of depression was twice the rate among direct result of their pain. The percentage of females who those who reported chronic pain as among those who did were limited in a few or more activities was higher than not and appeared to be related to age for both males and the percentage observed among males (77.7% versus females (Figure 9). The prevalence of depression was 70.7%). almost twice as high among individuals with chronic pain who were aged less than 65 years as among those 65 years Comparing individuals with chronic pain to those with- and older for both males and females (Figure 9). out revealed that the proportion requiring help with at least one task was substantially higher among those suf- Depression was also related to pain intensity for both fering from chronic pain than those who were free from sexes. Figure 10 shows that a higher level of pain intensity pain (Figure 11). was associated with a higher prevalence of depression. For those who suffered from chronic pain, employment Chronic pain affects daily tasks and can cause restrictions issues were very important. In this sample, it was found in daily activities. In both age categories (less than 65, and that the majority of those who were unable to work in the 65 and older) the majority of those who suffered from week before being interviewed suffered from pain (Figure chronic pain were limited in at least "a few" activities as a 12). Chronic pain also appeared to be associated with Page 5 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Proportion Requiring Help by Chronic Pain Ag Figure 11 e, Canada Status, Sex and Preval Figure 13 ence of Chronic Pain by Self-Rated Health, Canada Proportion Requiring Help by Chronic Pain Status, Prevalence of Chronic Pain by Self-Rated Health, Sex and Age, Canada Source: Statistics Canada, CCHS, Canada. Source: Statistics Canada, CCHS, 2000–2001 2000–2001 Preval Figure 14 ence of Chronic Pain by Self-Rated Stress, Canada Preval Figure 12 ence of Chronic Pain by Employment Variables Prevalence of Chronic Pain by Self-Rated Stress, Prevalence of Chronic Pain by Employment Varia- Canada. Source: Statistics Canada, CCHS, 2000–2001 bles Source: Statistics Canada, CCHS, 2000–2001 type of occupation, the prevalence being lowest among chronic pain and those with lower levels of stress had a professionals and highest in occupations in lower prevalence of chronic pain (Figure 14). manufacturing and natural resources. The association between type of occupation and prevalence of chronic In this analysis, social support was measured by a variable pain was similar among males and females. referred to as "tangible social support," which measures whether the individual had somebody to take them to the Poor self-rated health was inversely related to chronic doctor, do their chores, prepare meals or help if they were pain (Figure 13). Those who ranked their health as excel- confined to a bed. lent had the lowest prevalence of chronic pain, and the prevalence was highest among those who felt that their Figure 15 shows that there was a negative association health was poor. This trend was similar in both males and between chronic pain and perceived social support. Pain females. was reported more frequently by those who received less social support. This was true for males and females and Self-rated stress was related to chronic pain, in that those indicates that perceived social support is an important fac- who were extremely stressed had the highest prevalence of tor to consider in those with chronic pain. Page 6 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Societal Factors Associated with Chronic Pain Chronic pain sufferers have a substantial impact on the use of health care services. As shown in Figure 18, compar- isons for all selected indicators of health care utilization showed that use was higher among those who reported suffering from chronic pain than those who did not. Use of chiropractors, physiotherapists and alternative health care providers was lower among those 65 years and older. Medication use was higher among those reporting chronic pain than those not doing so for all medications in gen- eral and all selected types of medication (Figure 19). The use of pain medications such as pain relievers, Preva Canada Figure 15 lence of Chronic Pain by Perceived Tangible Support, tranquilizers, antidepressants and opiates was two to four Prevalence of Chronic Pain by Perceived Tangible times as high in those with chronic pain than in those Support, Canada Source: Statistics Canada, CCHS, 2000– without chronic pain. Discussion Characteristics of Chronic Pain Sufferers The chronic pain sufferer in Canada is more likely to be a woman than a man, although the gender difference is not tied exclusively to sex. Women also have lower incomes, less formal education and twice the prevalence of depres- sion, all of which were strongly associated with the report of chronic pain in this study. It thus seems reasonable to speculate that the differences in chronic pain evidenced in this CCHS were attributable to a combination of biologi- cal and psychosocial conditions specific to each sex. Not Percentage E Figure 16 thnicity of Those With Chronic Pain, by Sex, Age, surprisingly, chronic pain was also strongly associated Percentage of Those With Chronic Pain, by Sex, Age, Ethnicity Source: Statistics Canada, CCHS, 2000– with age and multiple chronic conditions. Women with chronic pain were more likely to report fibromyalgia, arthritis and migraine headaches, although there was no significant sex difference in the prevalence of back pain. In terms of potential impact, chronic pain was strongly related to reports of poor health, high levels of stress, low There do not seem to be major ethnic differences in levels of social support, more functional interference with chronic pain prevalence, with the notable exception of work and other activities, higher levels of dependence on two ethnic groups. For both sexes, in the age group 65 others, higher levels of health care utilization, and higher years and older the proportion of South Asians who medication usage. reported chronic pain was greater than for any other ethnic group. Chinese males and females had the lowest Treatment Approach rates for this age group. Among those aged less than 65 The "chronic" in chronic pain encapsulates the sense of years, Aboriginals had the greatest proportion of reported defeatism that characterizes the common attitude of many chronic pain, for both sexes (Figure 16). patients and health care providers who are dealing with this perplexing and debilitating problem. The etiology of In bivariate analysis, level of education was not associated most chronic pain syndromes remains largely unknown with chronic pain for either of the sexes or age groups. and, consequently, treatment efforts have consisted of pain management, at best, and narcotic dependence, at Figure 17 is a summary table of a multivariate logistic worst. Pain is a multi-dimensional problem not amenable regression model. The results of the regression show that to single causal pathway explanations or treatment when age, chronic conditions associated with pain, other approaches. It involves biological processes as well as cog- chronic conditions, income and education were nitive, emotional and social ones. Chronic pain thus controlled for, females did not have an increased risk of presents a challenge to both health care providers and chronic pain as compared with males. patients understandably searching for a quick and defini- tive solution. Page 7 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 L Figure 17 ogistic Regression of Variables Associated With Pain, Odds Ratios Logistic Regression of Variables Associated With Pain, Odds Ratios Source: Statistics Canada, CCHS, 2000–2001. Statistics Canada bootstrap programs used P Figure 18 ercentage Health Care Utilization in The Previous 12 Months, by Chronic Pain Status and Age Percentage Health Care Utilization in The Previous 12 Months, by Chronic Pain Status and Age. Source: Statis- tics Canada, CCHS, 2000–2001 Page 8 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 Medica Figure 19 tion Use in Previous Month by Chronic Pain Status and Age Medication Use in Previous Month by Chronic Pain Status and Age. Source: Statistics Canada, CCHS, 2000–2001 Multidisciplinary treatment is indicated for multi-dimen- Data Limitations sional problems such as chronic pain. In addition to med- The data source for the analysis in this chapter was cross- ical and physical therapy, cognitive-behavioural sectional in nature, and as a result causal pathways are dif- approaches have been shown to be important compo- ficult to infer. Also, since the survey was based on nents in treatment. Recent research indicates that behav- respondents' self-reports, the quality and accuracy of the ioural interventions are generally superior to medical data cannot be determined. Furthermore, the survey asked treatment controls in improving pain, decreasing respondents about only four specific chronic conditions disability and increasing activity levels.[22] These inter- that have been associated with chronic pain. Clearly, there ventions can also have the effect of teaching patients skills are many other conditions that can result in chronic pain. for continued self-care.[23] Gaps and Recommendations Implications for Health Care Utilization There are a number of gaps in the chronic pain and gender Despite the demonstrated effectiveness of multidiscipli- data currently available. One major gap is the lack of nary approaches to the treatment of chronic pain, it is detailed data on the types of chronic pain that women only a highly select group of patients who ever reach experience. Chronic pelvic pain is an example of a gender- multidisciplinary pain clinics. Most chronic pain patients specific pain tied to women's reproductive function for show a pattern of repeated consultations with primary which there is little Canadian, population-based data, care doctors and high levels of multiple consultations in despite ample U.S. evidence indicating that this is a major the hopes of finding the one who will solve the problem. women's health care problem. Endometriosis and This high level of consultation is sometimes also fuelled polycystic ovarian disease are just two of the common dis- by the search for more prescription analgesics, after the orders of reproductive function that result in chronic pel- tolerance of prior health care providers has been vic pain, although much of this pain is without obvious exhausted. The continuity of care becomes a major pathology. Vulvar vestibulitis and vulvodynia are also problem as patients skip from one provider to another. increasingly reported in both pre- and post-menopausal The elusive treatment is never found, drug dependence is women. Temporomandibular joint disorder (TMJ) is yet common, and the consequent expense is a major burden another example of a chronic pain disorder that affects on the Canadian health care system. predominantly women. Although specialty pain clinics are often perceived as A second major gap in the Canadian literature is system- expensive ventures, their treatment outcomes can result in atic data collection from sources other than self-reports. lower levels of patient disability. They are thus likely to Provincial databases of billing claims need to be investi- have an impact on health care utilization.[24] The gated to obtain a clearer picture of health care utilization, economics of health care may be such that high front-end prevalence of pain disorders and pain disorder-related investments may result in long-term health care savings patterns of analgesic medication prescription. The Phar- for the system as a whole. macare data from some provinces could be useful in Page 9 of 11 (page number not for citation purposes) BMC Women's Health 2004, 4:S17 http://www.biomedcentral.com/1472-6874/4/S1/S17 inferring the presence of chronic pain syndromes, as the efficient way to teach patients self-management strategies prevalence of heavy users of analgesic drugs could be that have been empirically shown to lead to significant detected using this source. In addition, many women decreases in pain, disability and medical consulta- report reproductive function-related pains to obstetricians tions.[23] As well, women have been shown to be more or gynecologists who often serve as their primary care amenable to this type of self-care than men. providers. Studies on women's health care need to increase the focus on this group of providers in addition Multidisciplinary pain clinics have demonstrated effec- to the existing focus on primary care doctors. Billing data- tiveness and may, in the long term, be the most bases may also serve to clarify the currently murky picture economical and effective recourse in the treatment of regarding chronic pain prevalence in different ethnic chronic pain. Rather than envision these as clinics within groups. Cultural differences in the acceptability of large, central metropolitan hospitals, perhaps smaller reporting pain may be obscuring ethnic trends that could community-based versions would better serve the popula- be directly targeted by public health efforts. tion in question. These smaller clinics would be more accessible to women who may be older, be disabled, or A third gap of particular importance to women is the lack have lower income and/or have children, and they could of assessment of the functional impact of chronic pain on also be tailored to the culturally specific characteristics of domestic responsibilities and parenting. The CCHS and the community. many other surveys have consistently shown a connection between reports of chronic pain and employment interfer- Conclusion ence, but there is very little investigation into the impact Chronic pain is a daunting problem for both individuals of pain on work in the home. This kind of functional and society. Its effects on quality of life and economic impairment gets lost in the employment data. If chronic costs demand attention as we enter the twenty-first pain is interfering with work outside the home, it is most century and plan for improvements in the delivery of likely also interfering with work inside the home. The lack health care to Canadians. The current age structure of the of assessment of this type of interference only serves to Canadian population indicates a large expected increase marginalize an important aspect of women's lives and in the number of individuals who are over the age of 65 hide the wide-ranging deleterious effect of chronic pain over the next 30 years. This necessarily means an increase on women and their families. in the prevalence of chronic pain, especially among women. Strategies for addressing this growing problem Filling these gaps in our knowledge about women and are needed to reduce the overall impact of chronic pain. pain is likely to prove integral to the development of The collection of more finely gradated information on the strategies designed to reduce the impact of chronic pain. nature and impact of chronic pain and health care utiliza- Certain recommendations, however, can already be sug- tion is necessary, yet health care delivery strategies cannot gested. Surveillance and early identification of pain wait for all of the information to be collected. The aim of disorders is crucial, as there are both theoretical and this survey and report is to make a contribution to future empirical reasons to believe that early treatment will data collection efforts and to ongoing and future result in better outcomes. Untreated pain can establish a applications centred on the care of both men and women central nervous system hold that becomes increasingly suffering from chronic pain. resistant to peripheral and other interventions. Long- standing pain can also result in behaviour patterns (e.g. References 1. Merskey H, Bogduk N: Classification of chronic pain 2nd edition. Seattle: lack of activity) that lead to other complicating disorders IASP Press; 1994. (e.g. obesity) and to cognitive and emotional problems 2. Fillingim RB: Sex, gender and pain: a biopsychosocial frame- (e.g. depression) that complicate treatment. Finally, the work. In: Sex, gender and pain Edited by: Fillingim RB. Seattle: IASP Press; 2000:1-6. more long-standing the pain, the more likely is the 3. Leresche L: Chronic pain. In: Behavioral medicine and women Edited dependence on narcotics and other pain medications. by: Blechman EA, Brownell KD. New York: The Guilford Press; 1998:788-792. 4. Unruh AM: Gender variations in clinical pain experience. Pain Primary care providers and obstetrician/gynecologists are 1996, 65:123-167. crucial to this surveillance and early detection effort. 5. Berkley KJ: Sex differences in pain. Behav Brain Sci 1997, 20:371-380. Assessment of pain needs to be incorporated into the first 6. Gear RW, Miaskowski C, Gordon NC, et al.: Kappa-opioids pro- consultation and targeted, even if it is not the primary rea- duce significantly greater analgesia in women than in men. son for the consultation. It then needs to be reassessed Nat Med 1996, 2:1248-1250. 7. Meana M: The meeting of pain and depression: comorbidity in periodically. Patient education about chronic pain syn- women. Can J Psychiatry 1998, 43(9):893-899. dromes is also important, as it can establish hopeful yet 8. Crook J, Rideout E, Browne G: The prevalence of pain com- plaints in a general population. Pain 1984, 18:299-316. realistic expectations and moderate the impulse to consult 9. 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Gen- eral Social Survey analysis series. Ottawa: Statistics Canada, Cat. No.0836- 043X 1994, 8:. 22. Becker N, Sjogren P, Bech P, et al.: Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain center compared to general practice: a randomized controlled trial. Pain 2000, 84:203-211. 23. Arnstein P, Caudill M, Mandle CL, et al.: Self-efficacy as the medi- ator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain 1999, 81:483-491. 24. Jensen MP, Turner JA, Romano JM: Correlates of improvement in the multidisciplinary treatment of chronic pain. J Clin Consult Psychol 1994, 62(1):172-179. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 11 of 11 (page number not for citation purposes)

Journal

BMC Women s Health – Springer Journals

Published: Aug 25, 2004

Keywords: Chronic Pain; Fibromyalgia; Health Care Utilization; Body Mass Index Category; Chronic Pelvic Pain

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