Journal of Pain & Palliative Care Pharmacotherapy

ISSN: 1536-0288 (Print) 1536-0539 (Online) Journal homepage: http://www.tandfonline.com/loi/ippc20

Chronic Diseases in the European Union: The

Prevalence and Health Cost Implications of
Chronic Pain

R. M. Leadley, N. Armstrong, Y. C. Lee, A. Allen & J. Kleijnen

To cite this article: R. M. Leadley, N. Armstrong, Y. C. Lee, A. Allen & J. Kleijnen (2012)
Chronic Diseases in the European Union: The Prevalence and Health Cost Implications
of Chronic Pain, Journal of Pain & Palliative Care Pharmacotherapy, 26:4, 310-325, DOI:
10.3109/15360288.2012.736933

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 Journal of Pain & Palliative Care Pharmacotherapy. 2012;26:310–325.
Copyright © 2012 Informa Healthcare USA, Inc.
ISSN: 1536-0288 print / 1536-0539 online
DOI: 10.3109/15360288.2012.736933

ARTICLE

Chronic Diseases in the European Union: The Prevalence

and Health Cost Implications of Chronic Pain
R. M. Leadley, N. Armstrong, Y. C. Lee, A. Allen, and J. Kleijnen
Downloaded by [Universitat Oberta de Catalunya] at 08:51 15 December 2017

AB STRACT
The objective of this study was to assess recent data on the prevalence of chronic pain as part of chronic dis-
eases; the prevalence of chronic pain as a chronic condition in its own right; the costs attributed to chronic
pain; and the European Union (EU) policies to addressing chronic pain. Recent literature was reviewed for data
on the prevalence and cost implications of chronic pain in the EU. Following on from an earlier systematic
review, 8 databases were searched for prevalence and 10 for cost information from 2009 to 2011 and rele-
vant EU organizations were contacted. Ten cost and 29 prevalence studies were included from the 142 full
papers screened. The general adult population reported an average chronic pain prevalence of 27%, which
was similar to those for common chronic conditions. Fibromyalgia had the highest unemployment rate (6%;
Rivera et al., Clin Exp Rheumatol. 2009;27[Suppl 56]:S39–S45) claims for incapacity benefit (up to 29.9%;
Sicras-Mainar et al., Arthritis Res Ther. 2009;11:R54), and greatest number of days of absence from work
(Rivera et al., Clin Exp Rheumatol. 2009;27[Suppl 56]:S39–S45). Chronic pain is common and the total pop-
ulation cost is high. Despite its high impact, chronic pain as a condition seems to have had little specific pol-
icy response. However, there does appear to be sufficient evidence to at least make addressing chronic pain
a high priority alongside other chronic diseases as well as to conduct more research, particularly regarding
cost.
KEYWORDS burden, chronic, cost, epidemiology, pain, prevalence

INTRODUCTION ally slow progression. Examples include cancer, car-

In December 2010, the Council of the European
Union (EU) adopted “Innovative approaches for
chronic diseases in public health and healthcare
systems,”3 which invited the European Commis-
sion and member states to initiate a reflection pro-
cess on chronic diseases/noncommunicable diseases
(NCDs). NCDs are noninfectious medical diseases
or conditions that are of long duration and gener-
R. M. Leadley, BSc, N. Armstrong, PhD, Y. C. Lee, BPharm, MSc, and
A. Allen, MSc, are with Kleijnen Systematic Reviews Ltd., York, United
Kingdom. J. Kleijnen, MD, PhD, is Director at Kleijnen Systematic Re-
views Ltd., York, United Kingdom, and is also with the School for Public
Health and Primary Care (CAPHRI), Maastricht University, Maastricht,
The Netherlands.
This paper was originally presented at the Societal Impact of Pain (SIP)
meeting held May 29–31, 2012, in Copenhagen, Denmark.
This study was funded by Grünenthal. The funding source did not have
any influence on the conduct and reporting of this review.
Address correspondence to: Regina M. Leadley, Kleijnen Systematic Reviews
Ltd., Unit 6, Escrick Business Park Riccall Road, Escrick York YO19 6FD,
United Kingdom (E-mail: regina@systematic-reviews.com)
diovascular disease, diabetes, chronic kidney disease,
and arthritis. Chronic pain, which is typically defined
as pain that lasts longer than 3 months, is often as-
sociated with chronic conditions4 and pain specialists
argue that it can be useful to consider chronic pain as
a chronic disease in its own right.5,6
Reid et al. (2011)7 investigated the epidemiology
of chronic noncancer pain in Europe and concluded
there was a lack of high-quality data on prevalence
and cost of chronic pain. Perhaps this is partly due to
chronic pain being seen not as a separate entity, but as
merely a symptom. To follow on from this report, we
have examined the most recent evidence on the preva-
lence of chronic pain both as part of chronic condi-
tions and as a chronic condition in its own right and
the health costs attributed to chronic pain. Further-
more, we investigated which policies and budgets in
the EU, as a whole and in member states, currently in-
clude reference to chronic pain. The resulting review
is also intended to form a basis for discussions about

310

chronic pain as an issue in the EU reflection process
on chronic diseases/noncommunicable diseases.
We addressed the following questions:
• What is the prevalence of chronic pain:
• As part of various chronic diseases?
• As a chronic disease in its own right?
• What is the impact in terms of cost of chronic pain?
• Which policies in the EU as a whole and in member
states currently include reference to chronic pain?
METHODS
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For question 1a, the population was patients with di-
agnoses of chronic diseases including but not limited
to cancer, diabetes, osteoarthritis, rheumatoid arthri-
tis, and fibromyalgia. The general adult population
was considered for the question 1b. Both the gen-
eral adult population and patients with diagnosis of
chronic diseases were considered for question 2. Only
moderate to severe chronic pain was included as de-
fined by the study authors. Studies that concerned
conditions such as migraine, headache, and angina
pectoris were excluded. For question 3, we looked for
policies of the EU and within the EU countries.
For question 1, we extracted and summarized data
on prevalence. For question 2, we extracted data on
resource use such as number of physician visits and
cost in each country’s currency as well as in euros.
Conversion into euros was carried out using the ex-
change rate for the cost year in the study. Resource
use and cost data were from the perspective of health
care payers, other public sector, e.g., social care, and
patient (lost work, travel expense) and society (lost
productivity). For question 3, we extracted a list of
statements regarding chronic pain, including in par-
ticular any reference to expenditure and priority.
For questions 1 and 2, included study types were
any report of primary research findings, including
reports of both single studies and reviews (any du-
plicates of studies were excluded). For question 3,
reports from government and specialist pain agen-
cies were included. The cutoff for recent was the last
5 years (2006–2011) in order to indicate current pol-
icy. No restrictions on language or publication status
were applied; however, data were only extracted from
publications in English.
Focused searches were undertaken to identify lit-
erature on the prevalence of chronic pain. MED-
LINE, Embase, Cochrane Database of Systematic
Reviews (CDSR), Database of Abstracts of Re-
views of Effects (DARE), Health Technology Assess-
ment Database (HTA), and National Health Service

C 2012 Informa Healthcare USA, Inc.
R. M. Leadley et al. 311
(NHS) Economic Evaluation Database (NHS EED)
were searched from September 2009 to 2011. These
databases were then searched to identify literature on
costs and economic burden of chronic pain, as were
Health Economic Evaluations Database (HEED)
and Cost-Effectiveness Analysis (CEA) Registry (In-
ternet). An EU countries filter was utilized where
appropriate. GIN International Guidelines Library,
NICE Guidance (Internet), National Guidelines
Clearinghouse (Internet), and INAHTA (Interna-
tional Network of Agencies for Health Technology
Assessment) (Internet) were searched for guidance
from September 2009 to 2011. OpenGrey (Inter-
net), OAIster (WorldCat), and King’s Fund Library
Database (Internet) were searched from 2005 to 2011
for gray literature. EU Ministries of Health Web sites,
professional bodies, associations, and societies were
also searched.
The full search strategy can be found in Ap-
pendix 1.
We also searched EU or country-specific Web sites
to find gray literature and national and international
guidelines and guidance. EU health ministries and
pain associations were searched and contacted for rel-
evant material.
This literature review followed the methods and
processes recommended in the Centre for Reviews
and Dissemination’s (CRD’s) “Systematic reviews:
CRD’s guidance for undertaking reviews in health
care.”8 Two reviewers independently inspected the
abstract of each reference identified by the search
and determined the potential relevance of each ar-
ticle. For potentially relevant articles, or in cases
of disagreement, the full article was obtained, inde-
pendently inspected, and inclusion criteria applied.
Any disagreement was resolved through discussion
and checked by a third reviewer. Justification for
excluding studies from the review has been docu-
mented. Quality assessment was carried out indepen-
dently by two reviewers using a checklist based on
the STROBE9 document. Any disagreements were
resolved by consensus. For each study, data were ex-
tracted by one reviewer and checked by a second re-
viewer. Any disagreements were resolved by consen-
sus. Data extraction was discussed and decisions doc-
umented.
RESULTS
From the references retrieved from the searches, 142
full text articles were selected and assessed in detail.
From these, 29 prevalence and 10 cost studies were
identified.
 312 Journal of Pain & Palliative Care Pharmacotherapy
Study Characteristics
The majority of prevalence studies were face-to-
face prospective studies, with some notable excep-
tions (Tables 1a and 1b). For example, Langley’s
2011 study was an Internet-based survey.10 Sauer
et al. (2011) also carried out their research retrospec-
tively by accessing the German GEK health insurance
records for 2007,11 and Breivik et al. (2009) carried
out a telephone survey.12
Some single studies provided us with a num-
ber of results; for example, Fernandez-de-la-Penas
et al. (2011) gave prevalences for both shoulder/neck
pain and for lower back pain in the general adult
population.13 Masajtis-Zagajewska et al. (2011) pro-
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vided figures for% prevalence in both the population
receiving dialysis and the population having had a
kidney transplant,14 whereas Klit et al. (2011) and
Neva et al. (2011) both investigated pain in their
chosen population and compared it with a reference
group.15,16
In total, there were 10 cost studies (Tables 2 and
3). The data collection was in six cases only through
questionnaire—face-to-face interview, postal, or self-
administered, in two cases medical records facilitated
by costing data from reimbursement authorities and
primary care centers, and in two cases mixed methods
were used. Countries included France, Spain, Ger-
many, Denmark, and Sweden and only one of the
studies, by Langley, targeted more than one coun-
try (United Kingdom, France, Spain, Germany, and
Italy).10
Six were related to back pain such as low back
pain, neck pain, and spinal pain, the rest covering
fibromyalgia,1 noncancer pain, or any (unspecified)
chronic pain. Of the 10 studies, 5 provided a defini-
tion of chronic pain. Depont et al. and Sicras-Mainar
et al. defined chronic pain as pain lasting at least 3
months.17,18 Depont et al. further specified that pain
should occur a minimum of once a week.17 Becker
et al. described chronic pain as pain that lasted for
at least 6 months.19 Muller-Schwefe et al. charac-
terized chronic pain as pain that caused more than
6 weeks’ sick leave or two prescriptions of opioids
within a period of 180 days.20 Rivera et al. defined
fibromyalgia according to guidance from the Amer-
ican College of Rheumatology (1990).1 Where there
was no clear definition, studies were included because
the term “chronic” was used to describe the pain. The
recruited samples in all studies were adult, but the
widest age range was greater than 18, the narrowest
being 35–75.1,17 There was only one study, by Holm-
berg and Thelin (2006) in Sweden, that sampled men
only; the rest of the studies consisted of both sexes,
with slightly more female than male.21
In terms of cost type, only one study reported pri-
vate/patient cost. The most commonly reported type
was health care (6 out of 10) and then cost of time off
work (4 out of 10). Total public sector cost (including
any category but private) was reported in 5 out of 10
studies.
Study Quality
The majority of the included prevalence studies were
of moderate to high quality, as judged by our quality
assessment tool (Table 4).9 Some moderate-quality
studies such as Berglund and Nordstrom (2001) and
Gerdle et al. (2008) provided no definition or mea-
surement of pain and so subjective perception of pain
was reported.22,23 Leijon and colleagues (2009) de-
scribed low back pain and neck-shoulder-arm pain
as pain a couple of days per week or every day.24,25
For our purposes, we have defined low back pain and
neck-shoulder-arm pain as chronic pain.
McGuire et al. (2010) showed some discrepan-
cies between number of questionnaire responses and
number of results recorded.26 Their study also only
categorized pain as mild or severe. This inadequate
categorization may have resulted in potentially viable
results (i.e., moderate pain) being classified as mild
and therefore not within our inclusion criteria. Walsh
et al. (2011) did a similar study using a higher number
of participants and categorizing pain as mild, moder-
ate, and severe.27 Here the prevalence was 31.1% as
compared with 1.3% for McGuire et al. (2010).26,27
The quality of the 10 costing studies was good
(Table 5). However, some failed to provide adequate
information for inclusion criteria, characteristics of
participants, and statistical methods. Depont et al.
(2010), Sicras-Mainar et al. (2009), and Becker et al.
(2010) were the only three out of the 10 studies that
met all the requirements in the quality assessment
list.2,17,19 In Muller-Schwefe et al. (2011), only source
of data and patients’ type of pain were mentioned in
the method section, further description of patients’
characteristics or other comorbidities was lacking.20
In Leboeuf-Yde et al. (2011) and Langley (2011),
the data were collected from cross-sectional question-
naires and international survey, respectively, and no
detailed information of participants’ details was pro-
vided; this was also the case with Kronborg et al.
(2009).10,28,29 In Holmberg and Thelin (2006), the
authors only recruited Swedish farmers in the study,
which was the only one out of the 10 studies that
failed to meet “study population is representative of
target population” in the quality assessment list.21
Question 1a: What is the prevalence of chronic pain
as part of various chronic diseases? Table 1a shows that
chronic pain was reported to be most prevalent in
Journal of Pain & Palliative Care Pharmacotherapy
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TABLE 1a. Pain as Part of Chronic Conditions—Prevalence Study Characteristics and Results

Definition of
Study ID Country chronic pain Population Type of pain Study design Sample size Age Prevalence (%)

Abbot 201131 UK nr Diabetes Diabetic Face-to-face 14,166 Mean 63.6 ± 35.0

neuropathy 11.8
Berglund 200122 Sweden nr Ehlers-Danlos Any Postal 77 Mean 39 71.0
Syndrome
Breivik 200912 Europe ≥5 (NRS Cancer Any Telephone 5084 nr 56.0
5–10),
recurrent
pain
Several times a
month or
more in the
last month
Ciaramitaro 201057 Italy nr Traumatic Neuropathic Face-to-face 158 Median 37 50.0
peripheral
injuries
Garcia de Paredes 201132 Spain nr Cancer Neuropathic Face-to-face 8615 nr 9.9
Gartner 200934 Denmark nr Unilateral breast Postoperative Postal 3253 18–70 24.5
cancer surgery
Gialloreti 200943 Italy 3 months Herpes Zoster Postherpetic Retrospective 5675 Range 6.2
neuralgia 15–85+
Hickey 201136 Ireland 2 months Mastectomy with Postoperative Face-to-face 42 PPSP 46.5 42.9
reconstruction No PPSP
52.5∗
Klit 2011 (i)15 Denmark nr Stroke Poststroke Postal 608 Median 72.6 39.0
Kuo 201158 UK nr Sarcoma Any Face-to-face 149 Median 62 53.0
Manas 201135 Spain nr Radiotherapy for Neuropathic Face-to-face 1098 Mean 61 31.1
cancer
Masajtis-Zagajewska 2011 (i)14 Poland 3 months Kidney Postoperative Face-to-face 114 Mean 46.6 51.1
transplant
Masajtis-Zagajewska 2011 (ii)14 Poland 3 months Dialysis Any Face-to-face 164 Mean 60.8 57.1
McGuire 201026 Ireland 6 months Intellectual Any Postal 157 Mean 36.9 1.3
disability
Neva 2011 (i)16 Finland 3 months Rheumatoid Back pain Postal 1076 Mean 65 RA 19.0
arthritis CP; 62 RA
no CP
Sauer 201011 Germany 3 months General adult Fibromyalgia Retrospective 1,646,284 nr 0.5
Voermans 201030 The nr Ehlers Danlos Musculoskeletal Postal 273 Mean 41 90.0
Netherlands Syndrome
Walsh 201127 Ireland 3 months Intellectual Any Postal 753 42 31.1
disability
Williams 201033 UK nr Head/neck Any Face-to-face 70 71% over 65 18.5
Cancer

Note. nr = not recorded; NRS = numeric rating scale (for clinical pain measurement); PPSP = persistent postsurgical pain; RA = rheumatoid arthritis; CP = chronic pain.

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314
TABLE 1b. Pain as a Chronic Condition in Its Own Right—Prevalence Study Characteristics and Results

Definition of Prevalence
Study ID Country chronic pain Population Type of pain Study design Sample size Age (%)

Baan 201142 Netherlands 3 months Elderly care Any Face-to-face 957 Mean 77.5 44.0
home
Fernandez-de-la-Penas 2011 (i)13 Spain nr General adult Shoulder/neck Face-to-face 29,478 Over 16 19.5
Fernandez-de-la-Penas 2011 (ii)13 Spain nr General adult Low back pain Face-to-face 29,478 Over 16 19.9
Frieem 200941 Germany 6 months Visiting Any Face-to-face 1201 Mean 53.4 40.0
outpatient
clinics
Gerdle 200823 Sweden 3 months General adult Musculoskeletal Postal 7637 Range 18–74 7.4
Hensler 200939 Germany 3 months General adult Any Face-to-face 1834 3/4 CP over 50 18.4
Horvath 201038 Hungary nr General adult Low back pain Face-to-face 9957 Average 42.1 44.1
Jakobsson 201037 Sweden 3 months General adult Any Postal 826 Average 58.9 46.0
Range
18–102
Klit 2011 (ii)15 Denmark nr General adult Any Postal 519 Median 71 28.9
Langley 201110 Europe 3 months General adult Any Retrospective 53,524 nr 16.6
Leijon 2009 a24 Sweden nr General adult Low back pain Postal 26,611 Mean 43.8 14.2
Leijon 2009 b25 Sweden nr General adult Neck/shoulder/arm Postal 34,707 Mean 43.8 18.0
Neva 2012 (ii)16 Finland 3 months General Adult Back pain Postal 1491 Mean 59 25.0
CP/54 no
CP
Raftery 201140 Ireland 3 months General adult Any Postal 1204 Mean46.8 35.5

Note. nr = not recorded; CP = chronic pain.

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TABLE 2. Cost Study Characteristics and Results (Euros Per Person Per Year)

Cost of
Definition of Public sector Health care Social care Private/patient incapacity benefit Cost of time
Study ID Country Type of pain Severity chronic pain cost cost cost cost type payments off work

Becker 201019 Germany Low back pain Any NR 3579.62 1707.62 NA NR NA 1872.00
Depont 201017 France Low back pain Severe 3 months NR 1431.20 NR NR NR NR
Holmberg 200621 Sweden Low back Any NR NA NA NA NA NA NA
pain/neck pain
Kronborg 200929 Denmark Noncancer Any NR NA NA 2021.05∗∗∗ 2064.80∗∗∗ NA NR
Langley 201110 5 EU Any Any NR NA NA NA NA NA NA
countries∗
Leboeuf-Yde 201128 Denmark Spinal pain Any NR NA NA NA NA NA NA
∗∗
Muller-Schwefe 201120 Germany Back pain Any 503.22 NR NR NA NA NR
Rivera 20091 Spain Fibromyalgia Any NR 9982.00 3245.80 NA NA 2266.90 4469.30
Schmidt 200944 Germany Back pain Any NR 2314.98 1095.83 NA NA NA 1219.51
Sicras-Mainar 20092 Spain Fibromyalgia Any 3 months 8654.30 1677.30 NA NA 6161.20 815.80
∗
The UK, France, Spain, Germany, and Italy.
∗∗
More than 6 weeks’ sick leave or two prescriptions of opioids within a period of 180 days.
∗∗∗
Converted to euros by multiplying cost in DKK by 0.1342.
NR = not reported; NA = not applicable; EU = European Union.

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316
TABLE 3. Time Off Work Study Characteristics and Results

Incapacity Incapacity
Definition of Days off benefit type benefit type
Study ID Country Type of pain Severity chronic pain Unemployed% work payments (%) definition Study design

Becker 201019 Germany Back pain Any 3 months 4.0 13.6 NA NA Internet-based
Depont 201017 France Low back pain Severe 3 months NA NA NA NA Face-to-face
Holmberg 200621 Sweden Low back Any NR NA NA 4.0 NR Self-administered
pain/neck pain questionnaire
Kronborg 200929 Denmark Low back pain Any NR NA NA NA NA Administrative
Langley 201110 5 EU countries∗ Back pain Any NR 5.1 NR NA NA Postal
Leboeuf-Yde 201128 Denmark Any Any NR NA NA 4.2 Disability Postal
pension
∗∗
Muller-Schwefe 201120 Germany Spinal pain Any NA 2.9 NA NA Administrative
Rivera 20091 Spain Fibromyalgia Any NR 6.0 73 11.9 Permanent Self-administered
working questionnaire and
disability administrative
Schmidt 200944 Germany Noncancer Any NR NA NA NA NA Face-to-face
Sicras-Mainar 20092 Spain Fibromyalgia Any 3 months NA 20.9 29.9 Permanent Telephone, postal,
disability and administrative
pension
∗
The UK, France, Spain, Germany, and Italy.
∗∗
More than 6 weeks sick leave or two prescriptions of opioids within a period of 180 days.
NR = not recorded; NA = not applicable.
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TABLE 4. Prevalence Studies Quality Based on STROBE Checklist

Adequate description Adequate description of

of outcomes (and losses to follow-up (for
Adequate how/how often longitudinal studies), loss
description of Adequate Study population is measured), e.g., Adequate Adequate to follow-up less than 10%
study design and description of representative of definition of chronic description of description of at 12 months, or less than
Study ID setting eligibility criteria target population pain statistical methods study participants 25% for longer follow-up

Abbot 201131 Yes Yes Yes No Yes Yes NA

Baan 201142 Yes Yes Yes Yes Yes Yes NA
Berglund 200122 Yes Yes Yes No Na Yes NA
Breivik 200912 Yes Yes Yes Yes Yes Yes NA
Ciaramitaro 201057 Yes Yes Yes No Yes Yes NA
Fernandez-de-la- Yes Yes Yes Yes Yes Yes NA
Penas
201113
Frieem 200941 Yes Yes Yes Yes Yes Yes NA
Garcia de Paredes Yes Yes Yes No Yes No NA
201132
Gartner 200934 Yes Yes Yes No Yes Yes NA
Gerdle 200823 Yes Yes Yes Yes Yes No NA
Gialloreti 200943 Yes Yes Yes Yes Yes Yes NA
Hensler 200939 Yes Yes Yes Yes Yes Yes NA
Hickey 201136 Yes Yes Yes Yes Yes Yes NA
Horvath 201038 Yes Yes Yes No Yes Yes NA
Jakobsson 201037 Yes Yes Yes Yes Yes Yes NA
Klit 201115 Yes Yes Yes No Yes Yes NA
Kuo 201158 Yes Yes Yes No Yes Yes NA
Langley 201110 Yes Yes Yes Yes Yes Yes NA
Leijon 2009 a24 Yes Yes Yes No Yes Yes NA
Leijon 2009 b25 Yes Yes Yes No Yes Yes NA
Manas 201135 Yes Yes Yes No Yes Yes NA
Masajtis-Zagajewska Yes Yes Yes Yes Yes Yes NA
201114
McGuire 201026 Yes Yes Yes Yes Yes Yes NA
Neva 201116 Yes Yes Yes Yes Yes Yes NA
Raftery 201140 Yes Yes Yes Yes Yes Yes NA
Sauer 201011 Yes Yes Yes Yes Yes Yes NA
Voermans 201030 Yes Yes Yes No Yes Yes NA
Walsh 201127 Yes Yes Yes Yes Yes Yes NA
Williams 201033 Yes Yes Yes No Yes Yes NA

Note. NA = not applicable.

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318
TABLE 5. Cost Studies Quality Based on STROBE Checklist

Adequate
description of Adequate description of
Study outcomes (and losses to follow-up (for
Adequate population is how/how often Adequate Adequate longitudinal studies), loss Results reported as
description of Adequate representative measured), description of description of to follow-up less than 10% unadjusted and
study design and description of of target exposures, statistical study at 12 months, or less than confounder-adjusted
Study ID setting eligibility criteria population predictors methods participants 25% for longer follow-up including precision

Becker 201019 Yes Yes Yes Yes Yes Yes Yes Yes
Depont 201017 Yes Yes Yes Yes Yes Yes Yes Yes
Holmberg 200621 Yes No No Yes Yes No Yes Yes
Kronborg 200929 Yes No Yes Yes Yes No Yes Yes
Langley 201110 Yes No Yes Yes Yes No No Yes
Leboeuf-Yde 201128 Yes No Yes No Yes No Yes Yes
Muller-Schwefe Yes No Yes Yes No No Na Yes
201120
Rivera 20091 Yes Yes Yes Yes Yes Yes Na Yes
Schmidt 200944 Yes Yes Yes No Yes Yes Yes Yes
Sicras-Mainar 20092 Yes Yes Yes Yes Yes Yes Yes Yes

Note. NA = not applicable.

 R. M. Leadley et al. 319

60
50
50

40 35
31.1
30

20
9.9
10 6.2

0
Herpes Zoster Cancer Cancer Diabetes Traumac
peripheral injuries
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Giallore 2009 Abbot 2011 Garcia de Paredes Manas 2011 Ciaramitaro 2010
2011

FIGURE 1. Percent prevalence of neuropathic pain as a type of chronic pain in various conditions.

those with Ehlers-Danlos syndrome (EDS), where up
to 90% of people with EDS suffered from chronic
pain.22,30 Other chronic conditions in which chronic
pain was reported to be highly prevalent were dia-
betes (35%),31 cancer (9.9–56%),12,32–36 and kidney
disease, i.e., dialysis and kidney transplant (57% and
51%, respectively).14 Figure 1 shows the prevalence
of neuropathic pain as part of various conditions and
Figure 2 shows the prevalence of chronic pain in can-
cer patients.
Question 1b: What is the prevalence of chronic pain
as a chronic disease in its own right? Table 1b shows
the prevalence of pain reported as a condition in its
own right, i.e., not as a result of any comorbidity.
Prevalence ranges from 7.4% to 46%23,37 (averaging
at 27%) in the general adult population, with back
pain13,16,24,38 and any specified type of pain being
most commonly reported.10,15,37,39–42
Chronic Pain Increases With Age
There appears to be a strong link between increasing
age and prevalence of chronic pain. This is shown in
the general population and more specifically with re-
gard to neck pain,13 lower back pain (LBP), and mus-
culoskeletal pain.23,38 Fernandez-de-las-Penas et al.
(2011) shows that the prevalence of neck pain
increases steadily from 9% in 16–30-year-olds to
28.5% in 51–70-year-olds and the prevalence of LBP
increases from 9.1% in 16–30-year-olds to 27.4% in
51–70-year-olds.13 Similarly, Horváth et al. (2009)

60

50

40

30

20

10

0
Cancer Head/Neck Breast cancer Cancer Breast cancer Sarcoma Cancer
Cancer
Garcia de Williams Gartner 2009 Manas 2011 Hickey 2011 Kuo 2011 Breivik 2009
Paredes 2011 2010

FIGURE 2. Percent prevalence of chronic pain in cancer.


C 2012 Informa Healthcare USA, Inc.
 320 Journal of Pain & Palliative Care Pharmacotherapy
presents data on the age-specific prevalence of LBP
where prevalence of pain increases from 12.5% in
14–19-year-olds to 59.1% in 60–65-year-olds.38 Ger-
dle et al. (2008) reports the prevalence of muscu-
loskeletal pain stratified by age where it increases from
2.4% in under 29-year-olds to 9.1% in >65-year-
olds.23 In the population with herpes zoster (HZ),
postherpetic neuralgia (PHN) has the highest preva-
lence in patients aged over 50, with these older pa-
tients accounting for 90.9% of all cases with PHN (3
months after HZ diagnosis).43
Question 2: What is the impact in terms of cost of
chronic pain? Cost of health care per patient per year
ranged from €1095 in Germany for back pain to
€3246 for fibromyalgia in Spain.1,44 Social care gen-
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erally cost a little less and incapacity benefit payments
were as high as €2267 for fibromyalgia in Spain.1
Altogether, public sector costs per patient per year
ranged from €2089 for low back pain in Germany
to €9982 for fibromyalgia in Spain.1,20
Tables 2 and 3 show that fibromyalgia had the
highest unemployment rate at 6%,1 highest claim rate
for incapacity benefit (11.9% in one study and 29.9%
in another),1,2 and greatest number of days of ab-
sence from work (73 from one study and 20.9 from
another).1,2 It also incurred the greatest costs;, for ex-
ample, public sector cost of €9982 from one study
and €8654 from another.1,2
Given that most data were available for “back
type” pain (LBP or back pain), a comparison between
countries (Germany and France) was possible, which
showed that health care costs varied little, between
€1096 in Germany and €1431 in France per person
per year.17,44 Cost of time off work in back pain was
only available in Germany, at €1219 in one study and
€1872 in another study annually.19,44
Unemployment attributed to pain ranged from 4%
in back pain in Germany to 6% in Fibromyalgia in
Spain.1,19 From the same studies, this coincided with
days off work of 13.6 and 73. Percentage receiving in-
capacity type benefit was very similar in most coun-
tries for back type pain at about 4%.21,28
All costs except that in one study by Kronborg
et al. were in euros.29 Those for the Kronborg et al.
study were published in Danish krona (DKK) and
converted into euros using the exchange rate for the
cost year in the study, i.e., 2009.45
Question 3: Which policies in the EU as a whole and
in member states currently include reference to chronic
pain? The government Web sites of all 27 European
member states, any international and European pain
organizations, and the European Commission were
searched for documents that mentioned budget al-
location for or the priority of chronic pain. Both
governments and pain organizations were contacted
to ask for possible relevant policy documents. Lit-
tle information that even mentioned chronic pain
could be found on Web sites and e-mail requests
did not yield additional information either. For ex-
ample, in the Major and Chronic Diseases report by
the European Commission’s Directorate-General for
Health and Consumers (DG Sanco), cardiovascular
disease, diabetes, and mental illness are perceived to
be “. . .dominant in mortality and morbidity. . ..”46 We
also searched the World Health Organization (WHO)
Web site and found a recent report on chronic dis-
eases, “Tackling chronic disease in Europe: Strate-
gies, interventions and challenges,”47 which states in
the introduction: “This book aims to complement
the two above-mentioned volumes [also on chronic
diseases] by focusing more explicitly on the strate-
gies and interventions that policy-makers have at their
disposal to tackle chronic diseases” (p. 2). However,
there is no mention of pain at all and one single men-
tion of musculoskeletal disease; most of the report fo-
cuses on cardiovascular disease (CVD).
Within the European Community Health Indica-
tors (ECHI) list of indicators published by the Euro-
pean commission towards a sustainable health mon-
itoring system in Europe, “general musculoskeletal
pain” is mentioned as indicator 37.48 Unfortunately,
this indicator has not been specified. Furthermore,
chronic pain is not listed on the Public Health Web
site under either “diseases” or “conditions” and we
could find no routinely collected European Council
(EC) or WHO statistics on the prevalence or cost of
chronic pain.49
However, there are some promising examples:
On 15 September 2011, the European Parliament
adopted a Resolution on the European Union’s po-
sition and commitment in advance to the United Na-
tions (UN) high-level meeting on the prevention and
control of noncommunicable diseases (NCDs). In
this Resolution, it states: “whereas the majority of
NCDs have common symptoms, such as chronic pain
and mental health problems, which directly affect suf-
ferers and their quality of life and should be addressed
by means of a common, horizontal approach, so that
health care systems can tackle these diseases more
cost-effectively.”50
In the operational plan for the “Strategic Im-
plementation Plan of the Pilot European Innova-
tion Partnership on Active and Healthy Ageing”
issued by European Commission, pain is referred
to several times.51 On page 26 of this document,
it states: “Chronic conditions, such as heart failure,
respiratory and sleep disorders, diabetes, obesity, de-
pression, pain, dementia, and hypertension affect
80% of people over 65, and often occur simultane-
ously (multimorbidity).”
Journal of Pain & Palliative Care Pharmacotherapy

In some member states, chronic pain has been
raised as a priority on the agenda treating it as
a disease. Examples are the Netherlands (see re-
port “Chronische pijn” published by the “Regier-
aad Kwaliteit van Zorg”) and Italy (see legge
038/2010).52,53 The Italian Law 038/2010 is the first
law in Europe that officially recognizes the citizens’
right to have access to pain therapy, in case of either
cancer or noncancer pain.
Stakeholder Responses
The European Federation of the International Asso-
ciation for the Study of Pain (IASP) Chapters (EFIC)
has been attempting to raise awareness of the impact
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of chronic pain in order to encourage policy that raises
its priority in order to better tackle chronic pain. This
is exemplified by the Societal Impact of Pain (SIP),
described as “an international platform created in
2010 and aims for
• raising awareness of the relevance of the impact that
pain has on our societies, health and economic sys-
tems
• exchanging information and sharing best-practices
across all member states of the European Union
• developing and fostering European-wide policy
strategies & activities for an improved pain care in
Europe” (http://www.sip-platform.eu).
Although the scientific framework of IASP is un-
der the responsibility of the European Federation of
IASP Chapters (EFIC), the pharmaceutical company
Grünenthal GmbH is responsible for funding and
nonfinancial support (e.g., logistical support).
The most recent activity of IASP was to produce
a “Road map for action.”44 It acknowledges the lack
of priority in the last 10 years since EFIC issued
its “Declaration on Chronic Pain as a Disease in
its Own Right”54 and, amongst other things, calls
upon European governments and EU organizations
to: “. . .acknowledge that pain is an important factor
limiting the quality of life and should be a top priority
of the national health care system . . . Strengthen pain
research (basic science, clinical, epidemiological) as
a priority in EU framework program and in equiva-
lent research road maps at national and EU level, ad-
dressing the societal impact of pain and the burden of
chronic pain on the health, social, and employment
sectors.” (p. 1)
The position that pain requires a higher priority
is also acknowledged in last year’s OPENminds re-
port where it recommends strategies that include the
following55 : “Make prevention and management of
chronic severe pain and its consequences a health care
policy priority; allocate adequate resources for organ-
isation, education and training of qualified personnel
to ensure optimal and adequate level of service to the

C 2012 Informa Healthcare USA, Inc.
R. M. Leadley et al. 321
large part of the population who suffer from chronic
pain conditions” (p. 21).
DISCUSSION
This project has provided recent estimates of the
prevalence of chronic pain within other chronic
diseases and as a chronic disease in its own right, and
the cost of chronic pain. What is generally apparent
is the high prevalence and cost of chronic pain. On
average, 80% of patients with EDS reported to suffer
from chronic pain. Of course, EDS is a rare condi-
tion, but more common conditions such as diabetes
and cancer reported average prevalences of 35% and
30%, respectively. In comparison, members of the
general adult population reported an average chronic
pain prevalence of 27%, which is quite similar to
those for chronic conditions. Cost per individual
is high. It also appears, at least at the level of the
European Commission, that chronic pain yet does
not have the adequate priority as evidenced by the
lack of mention in policy documents.
In comparison with Reid et al. (2011)7 who con-
ducted a review of epidemiology of chronic non-
cancer pain in Europe, we included cancer pain in
our inclusion criteria as cancer is a common chronic
disease/NCD. Reid et al. found 10 prevalence studies
and 9 cost studies as compared with our 29 preva-
lence studies and 10 cost studies. Given that we
searched for publications from 2009 to 2011, this
may indicate an increase in published research and
a higher priority for pain. Breivik et al. (2006) inves-
tigated chronic pain in Europe: prevalence, impact on
daily life, and treatment, and found the average preva-
lence of moderate to severe pain to be 19%.56 The lo-
cation and cause of pain was also reported. In 2009,
Breivik et al. went on to specifically examine cancer
pain in Europe (this 2009 paper is included as part of
our review).12
Our search strategy has been fully reported,
is reproducible, and focused on recent studies,
which should increase the validity of both cost
and prevalence estimates as an aid to present day
decision-making. Few data could be obtained from
the Web and there were few agency responses about
government policy. It is hoped, though, that with
increasing chronic pain as a priority, such data would
be easier to find.
Study Limitations
Although the findings of studies were variable, they
were consistent in reporting high prevalence and costs
of chronic pain. One limitation is the differences
between studies, which can make them difficult to
 322 Journal of Pain & Palliative Care Pharmacotherapy
compare directly. This can be explained by a range of
factors such as their locations, inclusion of different
populations, design, and definitions used. For exam-
ple, the majority of prevalence studies were based
on data from face-to-face prospective studies, but
some used Internet-based surveys or health insurance
records. Age ranges differed as well as the popula-
tions, such as the general adult population and popu-
lations with specific underlying diseases; and patients
with any chronic pain or specific chronic pain such a
back pain. Caution must be exercised in comparisons
between pain categories and countries given variation
in reporting and definitions, particularly of incapac-
ity benefit. Indeed, it is a strength to have converted
all monetary costs into euros, but the actual cost esti-
Downloaded by [Universitat Oberta de Catalunya] at 08:51 15 December 2017
mated in one country is unlikely to be entirely trans-
ferable due to variations in efficiency of provision of
services, e.g., the estimated cost might imply a par-
ticular length of hospital stay, which might not be the
same in another jurisdiction. However, conversion
was only required for one study. Also, in terms of cost,
we did not extract detailed data on resource use, e.g.,
the number of physician visits. However, our aim was
to estimate overall impact of chronic pain as opposed
to providing an analysis of costs. A further limitation
of this study is the timescale over which we have cho-
sen to examine published papers (2009–2011). This
was in part to follow on from the previous study by
our organization, i.e., Reid et al. (2011), which ex-
amined studies up until 2009 and also to provide the
most recent and up-to-date evidence. Also, we only
extracted data from the publications in English, so
some potentially valuable data may have been over-
looked from the three non-English publications we
did not data extract from.
CONCLUSIONS
Chronic pain is common both as part of a chronic dis-
ease and as a chronic condition in its own right and
the cost of chronic pain is high. Despite this high im-
pact, chronic pain as a condition seems to have had
little specific policy response. Of course, this review
has been based on a limited number of studies, partic-
ularly in terms of cost and incomplete access to policy
documents. There does, however, appear to be suf-
ficient evidence to at least make addressing chronic
pain a high priority alongside other chronic diseases
as well as to conduct more research, particularly re-
garding cost.
Main Findings
1. The overall impact of pain measured in terms of
prevalence and cost is high.
2. Chronic pain is most prevalent in those patients
with other chronic diseases.
3. Chronic pain can be considered as a very common
and costly chronic disease in its own right.
4. There is a strong link between increasing age and
prevalence of chronic pain.
5. Chronic pain is not adequately prioritized within
policies and budgets.
Declaration of interest: The authors report no con-
flicts of interest. The authors alone are responsible for
the content and writing of the paper.
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RECEIVED: 17 July 2012
REVISED: 30 August 2012
ACCEPTED: 28 September 2012
APPENDIX 1. Search Strategy
Incidence/Prevalence
Medline (OvidSP) 2009/08–2011/11/wk3
Date searched: 30.11.11
1 ((Chronic$ or longterm or long term or sus-
tained or long standing or permanent$ or
intractable$ or persistent$ or unremitting or
unrelenting or continual$ or continuous$ or
constant$ or unending or unceasing) adj3
(back$ or muscl$ or neck or shoulder$) adj3
(pain or pains or painful$ or sore$ or tender$
or discomfort or ache$ or aching or strains or
strained or sprain or sprains or sprained or in-
jur$ or damag$)).ti,ab. (6174)
2 Diabetic Neuropathies/ or exp polyneu-
ropathies/ or exp Mononeuropathies/ or exp
neoplasms/ or (cancer$ or neoplas$ or ma-
lignan$ or tumo?r$ or paraneoplas$).ti,ab.
(2709315)
3 (neuropath$ or arthralg$ or neuralg$ or fi-
bromyalg$ or DPN or mononeuropath$ or
polyneuropath$ or nerve$ pain$).ti,ab. (99897)
4 exp osteoarthritis/ or Arthritis, Rheumatoid/
or (rheumatoid arthrit$ or osteoarthrit$).mp.
(129683)
5 or/2–4 (2896176)
6 exp Pain/ or (pain or pains or painful$).ti,ab.
(467857)
7 5 and 6 (110967)
8 exp muscle, skeletal/ or muscl$.ti,ab. (541861)
9 exp Pain/ or (pain or pains or painful$ or sore$
or tender$ or discomfort or ache$ or aching
or strains or strained or sprain or sprains or
sprained or injur$ or damag$).ti,ab. (1462166)
10 8 and 9 (71006)
11 chronic disease/ (207208)
12 ((longterm or chronic$ or long term or sustained
or long standing or permanent$ or intractable$
or persistent$ or unremitting or unrelenting or
continual$ or continuous$ or constant$ or un-
ending or unceasing) adj2 (disorder$ or condi-
tion$ or illness$ or illhealth$ or ill health$ or
malad$ or sickness or disease$)).mp. (322306)
13 or/11–12 (322306)
14 13 and 6 (30590)
15 ((Chronic$ or longterm or long term or sus-
tained or long standing or permanent$ or
intractable$ or persistent$ or unremitting or
unrelenting or continual$ or continuous$ or
constant$ or unending or unceasing) adj2 (pain
or pains or painful$)).ti,ab. (31900)
16 pain, intractable/ or pain, referred/ (5394)
17 exp Back Pain/ (25320)
18 exp neuralgia/ (10979)
19 Neck Pain/ (3489)
20 exp Arthralgia/ (5828)
21 Fibromyalgia/ (5292)
22 low$ back pain$.mp. (17966)
Journal of Pain & Palliative Care Pharmacotherapy
 R. M. Leadley et al. 325

23 or/15–22 (81089) 51 (Ireland or irish or eire or Dublin$).ti,ab,in,hw.

24 or/1,7,10,14,23 (237746) (72041)
∗
25 morbidity/ (6090) 52 (Italy or Italian$ or rome or roman or Milan or
∗
26 Epidemiology/ (11623) naples or turin).ti,ab,in,hw. (396177)
∗
27 epidemiologic studies/ (943) 53 (Latvia$ or riga).ti,ab,in,hw. (1900)
∗
28 prevalence/ (541) 54 (Lithuania$ or Vilnius).ti,ab,in,hw. (4991)
∗
29 incidence/ (419) 55 (Luxembourg$ or luxemburg$).ti,ab,in,hw.
∗
30 Cross-Sectional Studies/ (269) (1795)
31 (morbidit$ or incidence$ or prevalen$ or epi- 56 (malta or maltese or Mdina or Notabile or Imd-
demiolog$).ti. (228570) ina).ti,ab,in,hw. (1446)
32 or/25–31 (239557) 57 (netherland$ or Holland or dutch or Amster-
33 24 and 32 (3279) dam or Rotterdam or hague or Utrecht or Eind-
34 ((Chronic$ or longterm or long term or sus- hoven).ti,ab,in,hw. (257657)
tained or long standing or permanent$ or 58 (polish or Poland or warsaw or Krakow or lodz
intractable$ or persistent$ or unremitting or or Wroclaw).ti,ab,in,hw. (99528)
Downloaded by [Universitat Oberta de Catalunya] at 08:51 15 December 2017

unrelenting or continual$ or continuous$ or 59 (portug?ese or Portugal or Lisbon or

constant$ or unending or unceasing) adj5 (pain
or pains or painful$ or sore$ or tender$ or
discomfort or ache$ or aching or strains or
strained or sprain or sprains or sprained or in-
jur$ or damag$) adj5 (morbidit$ or incidence$
or prevalen$ or epidemiolog$)).ti,ab. (1538)
35 Pain, Intractable/ep (87)
36 or/33–35 (4599)
37 European Union/ or EU.ti,ab. (17560)
38 (Europe$ adj3 (union or community)).ti,ab.
(8574)
39 (Austria$ or vienn$ or austro$).ti,ab,in,hw.
(78342)
40 (Belgium or belgian$ or Brussels or Antwerp$ or
ghent$).ti,ab,in,hw. (108106)
41 (bulgaria$ or sofia).ti,ab,in,hw. (15848)
42 (Cyprus or Cypriot$ or Lefkosia or
nicosia).ti,ab,in,hw. (1669)
43 (Czech$ or prague or praha).ti,ab,in,hw.
(59816)
44 (denmark or Danish or copenhagen or
Aarhus).ti,ab,in,hw. (116752)
45 (Estonia$ or Tallinn).ti,ab,in,hw. (4431)
46 (finland or finnish or finns or finn or
Helsinki).ti,ab,in,hw. (93800)
47 (france or French or paris$ or Marseille or
lyon or Toulouse or nantes or Strasbourg or
lille).ti,ab,in,hw. (478495)
48 (Germany or german$ or berlin$ or hamburg
or munich or munchen or cologne or koln or
Frankfurt or Stuttgart or dusseldorf).ti,ab,in,hw.
(628192)
49 (Greece or greek$ or Athens or Athenian or
Thessaloniki).ti,ab,in,hw. (79933)
50 (hungary or Hungarian$ or Bu-
dapest).ti,ab,in,hw. (47266)
porto).ti,ab,in,hw. (40136)
60 (Romania$ or Bucharest).ti,ab,in,hw. (15599)
61 (Slovakia$ or Bratislava or pozsony).ti,ab,in,hw.
(12821)
62 (slovenia$ or Ljubljana).ti,ab,in,hw. (9480)
63 (Spanish or spain or Madrid or Barcelona or Va-
lencia or Seville or Zaragoza or Malaga or Mal-
lorca or iberia$).ti,ab,in,hw. (253593)
64 (Swedish or Sweden or swede$ or Stockholm
or norrland or svealand or gotaland).ti,ab,in,hw.
(208162)
65 (Britain or british or wales or welsh or Scottish
or scots or Scotland or England or English or
Birmingham or leeds or London or Liverpool or
Manchester or Glasgow or Edinburgh or Cardiff
or Belfast or UK or GB or aberdeen).ti,ab,in,hw.
(2764338)
66 Austria/ or Belgium/ or exp france/ or exp Ger-
many/ or Bulgaria/ or Cyprus/ or Czech Re-
public/ or Denmark/ or Estonia/ or Finland/ or
Greece/ or hungary/ or Ireland/ or exp Italy/ or
Latvia/ or Lithuania/ or Luxembourg/ or malta/
or Netherlands/ or Poland/ or portugal/ or Ro-
mania/ or Slovakia/ or Slovenia/ or spain/ or Swe-
den/ or exp Great Britain/ (821907)
67 Mediterranean Islands/ or Baltic States/ (890)
68 or/37–67 (5428359)
69 36 and 68 (2021)
70 (200908$ or 200909$ or 20091$ or 2010$ or
2011$).ed. (1869690)
71 69 and 70 (372)
72 exp animals/ not humans.sh. (3722514)
73 71 not 72 (365)
74 remove duplicates from 73 (346)


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