Assessment of pain: a community-based diary survey in the USA

doi:10.1016/S0140-6736(08)60656-X

The Lancet

Volume 371, Issue 9623, 3–9 May 2008, Pages 1519-1525

https://doi.org/10.1016/S0140-6736(08)60656-X Get rights and content

Summary

Background

Pain is costly and a major reason for seeking medical care. Our aim was to assess the proportion of people experiencing pain, and the severity of pain, at randomly selected times in a representative sample of individuals in the USA.

Methods

A community-based telephone survey was designed that attempted to contact about 10 700 individuals by random-digit dialling. After collecting diary information for one 24-h period, ratings of pain on a 0–6 anchored scale for three randomly selected 15-min intervals of the day were obtained. Outcome measures were the proportion of intervals with non-zero pain, the proportion of intervals with pain above 3 (the scale midpoint), and the average pain rating. Activities of those individuals who reported substantial pain were also examined. To make the results representative of the US population, sample data were adjusted with sample weights developed by the Gallup Organisation.

Findings

3982 individuals were interviewed (response rate 37%). After adjustment for weighting, 28·8% of men and 26·6% of women reported feeling some pain at sampled times. Those with lower income or less education spent a higher proportion of time in pain and reported higher average pain than did those with higher income or more education. The average pain rating increased with age, although it reached a plateau between the ages of about 45 years and 75 years, with little difference between men and women. Satisfaction with life or health and the pain indicators tended to move in opposite directions.

Interpretation

The diary-survey methods described here could be used to study pain at the population level, and will enable the combination of pain assessments with information about activities of daily living.

Funding

US National Institute of Aging, Hewlett Foundation.

Introduction

Pain imposes considerable costs on the health-care system and economy. The occurrence of pain is a major reason that individuals seek medical attention and take medications. In the USA, over US$2·6 billion was spent on non-prescription analgesics in the 52 weeks ending March 25, 2007,¹ and in 2004—the most recent year with data available—$13·8 billion was spent on outpatient prescription analgesics.² Pain also decreases labour force participation and is estimated to cost over $60 billion a year in lost productivity.3, 4, 5

Our current understanding of people's experience of pain is limited to pain associated with certain conditions (eg, arthritis, back injury) and to those with chronic pain.6, 7, 8 Little is known about the prevalence or severity of daily pain from any origin. The US Centers for Disease Control and Prevention (CDC) recently did a survey of the number of days people recalled experiencing pain during the previous month,⁹ but this study's month-long recall period was likely to cause considerable distortion.¹⁰ Four studies from other countries provide estimates of the prevalence of any pain during a day or at the moment the survey was filled out. Gerdle and colleagues¹¹ found that 49% of a Swedish sample of 7637 individuals reported current pain in a postal survey (“Do you have pain anywhere in the body today?”) and Turunen,¹² who asked a sample of 4542 Finns in a postal survey about their point-in-time pain (“Do you feel any pain or ache right now, at this very moment?”), reported a rate of 37%. Buskila and colleagues¹³ reported that 44% of 2210 individuals in a southern Israel sample indicated pain on the day they were interviewed. Finally, a survey of 5000 Spaniards interviewed by telephone found that 30% of respondents had pain the previous day.¹⁴

A more complete understanding of the likelihood and manifestations of pain in the general population can give health-care providers and researchers a better sense of the circumstances that cause many individuals to seek medical treatment and of the background level of pain experienced by the general population. We developed a diary-based survey to estimate the occurrence and severity of pain in the general US population at representative moments (defined as 15-min intervals) of the day. We also obtained social and environmental descriptions of each episode to provide a more accurate and richer description of the pain experience than possible with previous studies.9, 15, 16, 17

Section snippets

Data collection

We designed the Princeton affect and time survey (PATS), which was based on the US Bureau of Labor Statistics' American time use survey (ATUS) and the day reconstruction method, a technique used to characterise experiences over the course of a day.¹⁸ The survey was administered by the Gallup Organisation (Omaha, NE, USA) in a telephone survey from May to August, 2006. An attempt was made to interview about 10 700 individuals aged 15 years or older using a random-digit dialling technique such

Results

3982 people completed the survey. The cooperation rate was 75% and the response rate was 37%. 2429 (61%) participants were women; 3504 (88%) were white; 677 (17%) had a disability; 3584 (90%) had a high school education or higher; and 1593 (40%) had a yearly household income of less than US$40 000. The average age of participants was 51·4 years (range 15–99). After weighting, the sample had fewer women (53%), higher income (36% below $40 000), fewer disabled (13%), and a lower average age (45·2

Discussion

Our findings show that by collecting time diary data with the procedures used in the ATUS, together with recalled emotional experiences, the PATS method could be used to describe a representative sample's experiences with pain. PATS provides a summary of how pain varies across respondents at randomly selected time intervals, which can be linked to the activities in which individuals engaged. Our use of one item to measure pain intensity at recalled episodes is consistent with recent consensus

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Cited by (114)

Investigating the risk factors for nonadherence to analgesic medications in cancer patients: Establishing a nomogram model
2024, Heliyon
The substantial prevalence of nonadherence to analgesic medication among individuals diagnosed with cancer imposes a significant strain on both patients and healthcare resources. The objective of this study is to develop and authenticate a nomogram model for assessing nonadherence to analgesic medication in cancer patients.
Clinical information, demographic data, and medication adherence records of cancer pain patients were gathered from the Affiliated Hospital of Chengde Medical University between April 2020 and March 2023. The risk factors associated with analgesic medication nonadherence in cancer patients were analyzed using the least absolute selection operator (LASSO) regression model and multivariate logistic regression. Additionally, a nomogram model was developed. The bootstrap method was employed to internally verify the model. Discrimination and accuracy of the nomogram model were evaluated using the Concordance index (C-index), area under the receiver Operating characteristic (ROC) curve (AUC), and calibration curve. The potential clinical value of the nomogram model was established through decision curve analysis (DCA) and clinical impact curve.
The study included a total of 450 patients, with a nonadherence rate of 43.33%. The model incorporated seven factors: age, address, smoking history, number of comorbidities, use of nonsteroidal antiinflammatory drugs (NSAIDs), use of opioids, and PHQ-8. The C-index of the model was found to be 0.93 (95% CI: 0.907–0.953), and the ROC curve demonstrated an AUC of 0.929. Furthermore, the DCA and clinical impact curves indicate that the built model can accurately predict cancer pain patients' medication adherence performance.
A nomogram model based on 7 risk factors has been successfully developed and validated for long-term analgesic management of cancer patients.
Guideline No. 443a: Opioid Use Throughout Women's Lifespan: Fertility, Contraception, Chronic Pain, and Menopause
2023, Journal of Obstetrics and Gynaecology Canada
To provide health care providers with the best evidence on opioid use and women’s health. Areas of focus include general patterns of opioid use and safety of use; care of women who use opioids; stigma, screening, brief intervention, and referral to treatment; hormonal regulation; reproductive health, including contraception and fertility; sexual function; perimenopausal and menopausal symptoms; and chronic pelvic pain syndromes.
The target population includes all women currently using or contemplating using opioids.
Open, evidence-informed dialogue about opioid use will lead to improvements in patient care and overall health.
Exploring opioid use through a trauma-informed approach offers the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Use should not be stigmatized, as stigma leads to poor “partnered care” (i.e., the partnership between the patient and care provider). Therefore, health care providers and patients must understand the potential role of opioids in women’s health (both positive and negative) to ensure informed decision-making.
A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, illicit drugs, fertility, pregnancy, breastfeeding, and aging.
The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).
All health care providers who care for women.
Opioid use can affect female reproductive function; health care providers and patients must understand the potential role of opioids in women’s health to ensure informed decision-making.
- 1.
  Opioid use by women is problematic in Canada and leads to addiction (high).
- 2.
  Overprescribing of opioids contributes to the opioid epidemic; women are prescribed opioids for pain relief more frequently than men and misuse of prescribed opioids is their primary pathway to addiction (high).
- 3.
  Opioids should be prescribed for pain relief only when all other evidenced-based treatments have failed and should be prescribed in the lowest possible dose for the shortest time possible (high).
- 4.
  Opioid use can cause hormonal changes, and chronic use is associated with hypogonadism (moderate), amenorrhea, and oligomenorrhea (high).
- 5.
  Long-term opioid use may cause infertility, primary ovarian insufficiency, and early menopause (moderate).
- 6.
  For women with an opioid use disorder, the transition to long-acting opioids (methadone or buprenorphine/naloxone) may improve fertility (high).
- 7.
  There is a complex relationship between trauma and mental health among women who misuse opioids (high).
- 8.
  Chronic pain and trauma symptoms improve when treated together, using an interdisciplinary approach (low).
- 9.
  Opioid misuse or continued opioid use for chronic pain may reveal other biopsychosocial factors and pain conditions that need to be evaluated (moderate).
- 10.
  Chronic opioid use is a risk factor for bone loss (moderate).
- 1.
  A trial of opioid therapy should only be considered when all other first line treatment options have failed for acute post-operative pain and concurrent physical and mental health comorbidities are stabilized before use (conditional, low).
- 2.
  Health care providers must discuss the risks and benefits of prescribed opioids for treatment of pain, and/or and transition to opioid agonist therapy for substance use disorder on reproductive health and outcomes, during pre-conception counselling (conditional, moderate).
- 3.
  For women who use opioids, health care providers should recommend long-acting reversible contraceptives (subdermal implants or intrauterine devices) for contraception (strong, high).
- 4.
  In women with a history of substance use, opioids should be used with caution for the treatment of chronic pelvic pain, and only if all other evidenced-based treatments have failed (conditional, moderate).
- 5.
  Opioid use for post-operative pain control must be carefully monitored; continued use beyond the typical healing period may indicate a transition from acute to chronic pain (conditional, moderate).
- 6.
  Women should be asked about their use of opioids when they present to health care providers for pain management; health care providers should use screening, brief intervention, and referral to treatment (SBIRT) to help to connect patients to treatment (strong, high).
- 7.
  Evidence-based interventions for opioid use should be tailored to the specific trends and needs among different populations, including adolescents, young adults and older women (conditional, moderate).
- 8.
  Women exposed to chronic opioids at doses of more than 100 mg morphine equivalents daily for 3 months should be screened for osteoporosis starting at age 50 years, given the higher risk of endocrinopathy and hypogonadism among women on opioid therapy (strong, moderate).
- 9.
  Women over the age of 65 should be maintained on buprenorphine as a first-line treatment for opioid use disorder, and methadone as second-line; tapering and adjuvant medications for withdrawal should be used with caution (conditional, moderate).
Directive clinique n<sup>o</sup> 443a : Opioïdes aux différentes étapes de la vie des femmes : Fertilité, contraception, douleur chronique et ménopause
2023, Journal of Obstetrics and Gynaecology Canada
Fournir aux professionnels de la santé les meilleures données probantes sur l’utilisation des opioïdes et la santé des femmes. Les items suivants seront abordés portent sur les profils généraux d’utilisation et l’innocuité des opioïdes; les soins aux femmes qui utilisent des opioïdes; la stigmatisation, le dépistage, l’intervention brève et l’orientation vers le traitement; la régulation hormonale; la santé reproductive, y compris la contraception et la fertilité; la fonction sexuelle; les symptômes périménopausiques et ménopausiques; et les syndromes de douleur pelvienne chronique.
Toutes les femmes qui utilisent ou envisagent d’utiliser des opioïdes.
Un dialogue ouvert et éclairé sur l’utilisation des opioïdes permettra d’améliorer les soins aux patientes et leur santé globale.
La discussion sur l’utilisation d’opioïdes par une approche tenant compte des traumatismes actuels ou antérieurs donne au professionnel de la santé à la patiente l’occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés sur leurs soins. Elle favorise le diagnostic et le traitement possible du trouble lié à l’utilisation d’opioïdes. L’utilisation ne doit pas être stigmatisée, car la stigmatisation affaiblit la relation et le partenariat essentiel entre les professionnels de la santé et les femmes. Par conséquent, les professionnels de la santé et les patientes doivent comprendre les impacts et le rôle potentiel des opioïdes sur santé leur (tant positif que négatif) pour assurer une prise de décision éclairée.
Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d’août 2018 à mars 2023 à l’aide des termes MeSH et mots clés suivants (et variantes) : opioids, illicit drugs, fertility, pregnancy, breastfeeding et aging.
Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l’annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l’interprétation des recommandations fortes et faibles).
Tous les professionnels de la santé qui prodiguent des soins aux femmes.
La consommation d'opioïdes peut affecter la fonction reproductive féminine ; les prestataires de soins de santé et les patients doivent comprendre le rôle potentiel des opioïdes dans la santé des femmes afin de pouvoir prendre des décisions en connaissance de cause.
- 1.
  La consommation d'opioïdes par les femmes est problématique au Canada et conduit à la dépendance (élevée).
- 2.
  La prescription excessive d'opioïdes contribue à l'épidémie d'opioïdes ; les femmes se voient prescrire des opioïdes pour soulager la douleur plus fréquemment que les hommes et le mésusage des opioïdes prescrits est leur principale voie d'accès à la dépendance (élevée).
- 3.
  Les opioïdes ne doivent être prescrits pour soulager la douleur que lorsque tous les autres traitements fondés sur des données probantes ont échoué, et doivent être prescrits à la dose la plus faible possible pendant la durée la plus courte possible (élevée).
- 4.
  L’utilisation d’opioïdes peut causer des changements hormonaux, et l’utilisation chronique est associée à l'hypogonadisme (moyenne), l’aménorrhée et à l’oligoménorrhée (élevée).
- 5.
  L'utilisation à long terme d'opioïdes peut entraîner une infertilité, une insuffisance ovarienne primaire et une ménopause précoce (moyenne).
- 6.
  Chez les femmes présentant un trouble lié à l’utilisation d’opioïdes, la transition vers les opioïdes à action prolongée (méthadone ou buprénorphine-naloxone) peut améliorer la fertilité (élevée).
- 7.
  Il existe une relation complexe entre les traumatismes et la santé mentale chez les femmes qui font un usage abusif d'opioïdes (élevée).
- 8.
  Les symptômes de douleur chronique et de traumatisme s’atténuent lorsqu’ils sont traités ensemble selon une approche interdisciplinaire (faible).
- 9.
  Le mésusage d'opioïdes ou l'utilisation continue d'opioïdes pour une douleur pelvienne chronique peut révéler d'autres facteurs biopsychosociaux et conditions de douleur qui doivent être évalués (moyenne).
- 10.
  L'utilisation chronique d'opioïdes est un facteur de risque de perte osseuse (moyenne).
- 1.
  L'essai d'un traitement opioïde ne doit être envisagé que lorsque toutes les autres options de traitement de première ligne ont échoué pour la douleur postopératoire aiguë et que les comorbidités physiques et mentales concomitantes sont stabilisées avant d'être utilisées (conditionnelle, faible).
- 2.
  Les professionnels de la santé doivent discuter des risques et des avantages des opioïdes prescrits pour le traitement de la douleur, et/ou de la transition vers un traitement par agoniste opioïde pour les troubles liés à l'utilisation de substances, sur la santé et les résultats en matière de procréation, au cours du conseil préconceptionnel (conditionnelle, moyenne).
- 3.
  Pour les femmes qui utilisent des opioïdes, les professionnels de la santé doivent recommander des contraceptifs réversibles à longue durée d'action (l’implant sous-cutané ou un dispositif intra-utérin) comme mode de contraception (forte, élevée).
- 4.
  Chez les femmes ayant des antécédents de consommation de substances psychoactives, il faut faire preuve de prudence en prescrivant des opioïdes pour traiter la douleur pelvienne chronique; on doit les prescrire seulement en cas d’échec des autres traitements fondés sur des données probantes (conditionnelle, moyenne).
- 5.
  L'utilisation d'opioïdes pour le contrôle de la douleur postopératoire doit être soigneusement surveillée ; une utilisation continue au-delà de la période de guérison typique peut indiquer une transition de la douleur aiguë à la douleur chronique (conditionnelle, moyenne).
- 6.
  Les femmes devraient être interrogées sur leur consommation d'opioïdes lorsqu'elles se présentent aux prestataires de soins pour un traitement de la douleur ; les prestataires de soins devraient utiliser le dépistage, l'intervention brève et l'orientation vers un traitement (SBIRT) pour aider à orienter les patients vers un traitement (forte, élevée).
- 7.
  Les interventions fondées sur des données probantes concernant la consommation d'opioïdes doivent être adaptées aux tendances et aux besoins spécifiques des différentes populations, y compris les adolescents, les jeunes adultes et les femmes âgées (conditionnelle, moyenne).
- 8.
  Les femmes exposées à des opioïdes chroniques à des doses supérieures à 100 mg d'équivalents morphine par jour pendant 3 mois devraient faire l'objet d'un dépistage de l'ostéoporose à partir de l'âge de 50 ans, étant donné le risque plus élevé d'endocrinopathie et d'hypogonadisme chez les femmes sous traitement opioïde (forte, moyenne).
- 9.
  Les femmes âgées de plus de 65 ans doivent être maintenues sous buprénorphine comme traitement de première intention pour les troubles liés à l'utilisation d'opioïdes, et sous méthadone comme traitement de deuxième intention ; la réduction progressive et les médicaments adjuvants pour le sevrage doivent être utilisés avec précaution (conditionnelle, moyenne).
Management of Chronic Pain in Nursing Homes: Navigating Challenges to Improve Person-Centered Care
2021, Journal of the American Medical Directors Association
Despite the dynamic demands in the nursing home (NH), a definitive approach to managing chronic pain in older adults has yet to be established. Due to concerns for potential adverse pharmacologic effects, balancing appropriate pain management is a challenge among NH residents. The challenges encompass but are not limited to medical complexities, functional disabilities, and physical frailty. Barriers to the successful implementation of a comprehensive chronic pain management at the NH may include ambiguous directions on specific therapeutic interventions, insufficient guidance on treatment duration, and limited available treatment options. The Centers for Medicare and Medicaid Services’ reporting requirement of adequate pain control among NH residents coupled with widely variable clinician-prescribing habits highlights the difficulties in overcoming the preceding challenges and barriers. The Coronavirus Disease 2019 (COVID-19) pandemic has further complicated pain management due to its negative consequences on well-being of residents of NHs. Associated symptoms of psychosocial stress, anxiety and depression, and chronic pain symptoms can exacerbate during the COVID-19 pandemic, leading to increased requirement for pain medications including but not limited to opioids.
Pain is a multidimensional symptom and requires a strategic multimodal approach for its management. Nonpharmacologic modalities are underutilized in the NH setting and are the preferred first steps for mild pain, and nonopioid pharmacological agents can be added as a second step for a synergistic effect for moderate to severe pain. Opioids should be used as a last resort. Short-acting opioids are preferred over extended-release/long-acting opioids for chronic pain. Clinicians are encouraged to engage residents in proactive strategies in managing their pain, and to set realistic expectations toward improving their quality of life, as complete elimination of pain is not feasible in most cases.
This review article provides the interdisciplinary team with a contemporary perspective of the multitude of changes and challenges influencing the prescribing as well as deprescribing of various pain medications.
III. Detecting Treatment Effects in Clinical Trials With Different Indices of Pain Intensity Derived From Ecological Momentary Assessment
2021, Journal of Pain
Pain intensity represents the primary outcome in most pain clinical trials. Identifying methods to measure aspects of pain that are most sensitive to treatment may facilitate discovery of effective interventions. In this third of 3 articles examining alternative indices of pain intensity derived from ecological momentary assessments (EMA), we compare treatment effects based on Average Pain, Maximum Pain, Minimum Pain, Pain Variability, Time in High Pain, Time in Low Pain, and Pain After Wake-Up. We also examine which indices contribute to Patient Global Impressions of Change (PGIC). Data came from 2 randomized, double-blind, placebo-controlled trials examining the efficacy of milnacipran for fibromyalgia treatment; 2,084 patients provided >1 million EMA pain intensity ratings over 24 (Study 1) or 26 (Study 2) treatment weeks. Pain Variability and Time in High Pain produced significantly smaller treatment effects than Average Pain; other pain indices showed effects that were numerically smaller, but not significantly different from Average Pain. Changes in all pain indices were significantly associated with PGIC, with improvements in Maximum Pain and in Pain Variability offering small incremental contributions to understanding PGIC over Average Pain. Results suggest that different pain indices could be used to detect treatment effects in pain clinical trials.
Alternative summary measures of pain intensity derived from EMA may broaden the scope of outcomes useful in pain clinical trials. In this analysis of a pharmacological treatment for fibromyalgia, most pain summary measures indicated similar effects; improvements in Maximum Pain and Pain Variability contributed to understanding PGIC over Average Pain.
II. Indices of Pain Intensity Derived From Ecological Momentary Assessments and Their Relationships With Patient Functioning: An Individual Patient Data Meta-analysis
2021, Journal of Pain
Pain intensity is a complex and dynamic experience. A focus on assessing patients’ average pain levels may miss important aspects of pain that impact functioning in daily life. In this second of 3 articles investigating alternative indices of pain intensity derived from Ecological Momentary Assessments (EMA), we examine the indices’ associations with physical and psychosocial functioning. EMA data from 10 studies (2,660 patients) were reanalyzed to construct indices of Average Pain, Maximum Pain, Minimum Pain, Pain Variability, Time in High Pain, Time in Low Pain, Pain after Wake-up. Three sets of individual patient data meta-analyses examined 1) the test-retest reliability of the pain indices, 2) their convergent validity in relation to physical functioning, fatigue, depression, mental health, and social functioning, and 3) the incremental validity of alternative indices above Average Pain. Reliabilities approaching or exceeding a level of .7 were observed for all indices, and most correlated significantly with all functioning domains, with small to medium effect sizes. Controlling for Average Pain, Maximum Pain and Pain Variability uniquely predicted all functioning measures, and Time in High Pain predicted physical and social functioning. We suggest that alternative pain indices can provide new perspectives for understanding functioning in chronic pain.
Alternative summary measures of pain intensity derived from EMA have the potential to help better understand patients’ pain experience. Utilizing EMA for the assessment of Maximum Pain, Pain Variability, and Time in High Pain may provide an enhanced window into the relationships between pain and patients’ physical and psychosocial functioning.

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ArticlesAssessment of pain: a community-based diary survey in the USA

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Data collection

Results

Discussion

Pain

Pain

Eur J Pain

Lancet

Pain

Pain

J Pain

Top generics based on retail dollar sales

Chain Drug Rev

The top five therapeutic classes of outpatient prescription drugs ranked by total expense for adults age 18 and older in the U.S. civilian non-institutionalized population, 2004. Statistical Brief 154

Education, disability and the prevalence of pain

Lost productive time and cost due to common pain conditions in the US workforce

JAMA

Dynamics of work disability and pain. Working paper

Prevalence of chronic benign pain disorder among adults: a review of the literature

Pain

Articles
Assessment of pain: a community-based diary survey in the USA