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Pain: The 5th Vital Sign?

New studies document pain's toll and the best ways to manage it

TUESDAY, Nov. 11, 2003 (HealthDayNews) -- As a family medicine physician, Dr. Elizabeth H.B. Lin sees a good many older patients with arthritis, not to mention a good many older patients with depression.

And while arthritis pain is bad enough in people without depression, it can be almost unbearable in those with depression, she says.

"Those with arthritis and depression reacted differently to the arthritis," Lin says. "They were overwhelmed by pain. They said things like, 'Knee pain is ruining my life.'"

The observation inspired the Seattle physician to conduct a randomized study to see if treatment for depression also improved pain and function in elderly adults.

The answer in a nutshell was "yes" -- treating depression did decrease arthritis pain and improved functioning and overall quality of life.

Lin's findings and those of several other studies on pain appear in the Nov. 12 issue of the Journal of the American Medical Association, a special themed issue on pain management.

"Pain is the most prevalent health condition," says Walter Stewart, director of the Outcomes Research Institute in Danville, Pa., and author of another study in the journal. He made his comments at a press briefing in New York City on Nov. 11 to unveil the issue.

Stewart and his colleagues found lost productivity time from pain costs U.S. employers an estimated $61.2 billion a year.

Interestingly, only $14.3 billion of that total was from absenteeism. The lion's share, $46.9 billion, was from "presenteeism," or reduced performance on the job.

Long-term disability and short-term disability also represented a small share of the overall cost. The biggest costs came from work absence and reduced performance on the job.

"Disability is well tracked by employers because that's where the data is, not where the problem is," Stewart says.

Stewart's team looked at data from the American Productivity Audit, a telephone survey of working adults conducted from Aug. 1, 2001, through July 31, 2002. During that time, 30,523 interviews were conducted. Participants were asked questions about their experience with the four most common types of pain -- headache, back pain, arthritis, and other musculoskeletal pain -- and work during the previous two-week period.

The greatest loss of productivity occurred among those with "high-control" jobs (i.e. those with a lot of control over their time), as well as among those with less education and among blacks.

The education dimension may be the simplest to explain, Stewart says. "Their physical environments and job stressors tend to be more severe," he says. "They have poor access to health care, lower health literacy and higher levels of depression, which may exacerbate the pain experience."

In all, 5 percent of people account for 29 percent of total hours lost due to pain. "A minority of individuals account for the majority of lost time," Stewart says. In any two-week period, one in eight workers reported "loss in productive time" and that person, on average, lost five hours per week.

Another study in the journal found that using cox-2 inhibitors, a specific type of nonsteroidal anti-inflammatory drug (NSAID), both before and after knee-replacement surgery significantly reduced pain. The drugs also decreased the use of painkillers, lessened sleep disturbances, and increased the post-surgery range of motion of the knee.

Both groups of patients in the randomized study -- those who received cox-2 inhibitors and those who did not -- also received epidural analgesics. According to study author Dr. Asokumar Buvanendran, knee surgery is one of the most painful types of surgery, along with respiratory and abdominal operations.

Finally, Dr. Richard Howard of Great Ormond Street Hospital for Children in London discussed at the press briefing the particular challenges of treating pain in children.

"Children and children in pain rarely seem to get the attention they need," he says. And although much progress has been made in the last 20 years, much more still needs to be done.

As experts are recognizing, the nervous systems of children are very different from those of adults, and few drugs are actually tested on this younger complement of patients, Howard says.

Adds Stewart: "We would like pain to be the fifth vital sign. But we haven't figured out how to seamlessly access it in a way that is effective." (The other four major vital signs are temperature, blood pressure and pulse and respiratory rates.)

Because so much pain is reported first to the family physician, "the challenge is in the primary-care box," Stewart says.

More information

For more on pain management, visit the American Pain Foundation or the American Society of Anesthesiologists.

SOURCES: Nov. 11, 2003, press briefing, Journal of the American Medical Association, New York City, with Elizabeth H.B. Lin, M.D., family medicine physician and researcher, Group Health Cooperative, Seattle; Walter Stewart, Ph.D., director, Outcomes Research Institute, Center for Health Research and Rural Advocacy, Geisinger Health Systems, Danville, Penn.; Asokumar Buvanendran, M.D., assistant professor, anesthesiology, Rush University Medical Center, Chicago; Richard Howard, M.D., consultant, pediatric anesthesia and pain management, Great Ormond Street Hospital for Children, London; Nov. 12, 2003, Journal of the American Medical Association
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