An update on Pain and Palliative Services in the Middle East.

Dr Vahid MohabbatiSpecialist Pain Medicine Physician

Specialist Palliative Medicine PhysicianThe University of Sydney

Royal Prince Alfred HospitalInternational Conference and Exhibition on Pain Medicine, Chicago

June 2015

Demographics of the Middle East

• 17(12) Middle East countries• Population in 2008 was 356 million persons

i.e. 5.3% of the world population• The population growth rate in the Middle East

is among the highest in the world. • The two most populous countries in this

region (Iran and Egypt) have a population higher than that of Italy, the UK and France!

Demographics

• The youth dependency ratio is also very high in most of these countries, the highest in West Bank and Gaza (85) and Yemen (80).

• Large gender differences exist in their population structure, labor force participation rates and literacy rates.

• Life expectancy at birth is much lower

Demographics

• Non-communicable diseases were the major cause of death for most countries

• There are major demographic, economic and political differences across the countries that from the Middle East. http://www.credit-suisse.com/researchandanalytics

Imperative

• There’s strong argument that chronic pain is a disease of it’s own right and should be regarded as a chronic disease condition with its implications for clinical management.

• Chronic pain is also a recognized under reported symptom in chronic diseases. (Non-malignant)

• There is also increased awareness of the need for pain and symptom management as well as palliative care for chronic diseases.

Imperative

• Huge unmet need for pain and palliative services in that part of world according to the WHO. WHO Global Atlas on Palliative Care at The End of Life, http://www.thewhpca.org/resources/global-atlas-on-end-of-life-care

• Lack of awareness of societal/individual impacts of pain amongst health professionals and general public. Siddall PJ, Cousins MJ. Persistent pain as a disease entity: Implications for clinical

management. Anesth Analg 2004;99:510–20 • lack of availability of prescription opioids and opioid

varieties for use in the community and for end of life care. Seya MJ, Gelders SF, Achara OU, Milani B, Scholten WK. A first comparison between the consumption of and the need for opioid analgesics at country, regional, and global levels. J Pain Palliat Care Pharmacother 2011; 25(1):6 -18

Imperative

– No published data in Iran on chronic pain prevalence in general public

– A literature search using term “pain” from 1946 to present yielded 226 papers with only 95 used “chronic pain” or “persistent pain” in their title or content.

– 13/226 looked at small subgroups of population with pain

– A similar search using term “palliative care” yielded only 8 papers!!

Aims

• Our study attempts an initial assessment of chronic pain in a community sample of urban Shiraz population of Iran in order to find the gaps in alleviating the suffering of people in need of pain management in Iran.

Methods

• A cross sectional population-base survey.• Study conducted in 114 postal zones of Shiraz

in spring 2012.• Our questionnaire was educed, adjusted and

translated from “Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment” developed by Breivik et al. Breivik H, Collett B,

Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10(4):287-333.

Methods

• A multistage stratified cluster method was used, dividing Shiraz city into districts, and then selecting districts randomly into blocks and finally dwellings on the blocks were selected randomly.

• Face-to-face screening interviews were delivered by trained interviewers.

• The minimum required sample size was calculated to be at least 1000 participants.

• 1050 participants were interviewed.

Inclusion criteria

• Age greater than 18 years • Residents of Shiraz• Presence of chronic pain for at least six months • Frequency of pain ≥ twice weekly

Exclusion criteria

• History of previous serious mental illness or developmental disabilities.

• Pain duration less than 6 months (N=78)• The last experience of pain > one month ( N=69)• Pain experienced per week < two times (N=87)• The intensity of last experienced pain was ≤ 4 on an 11-point

NRS scale(N=26)

Selection process

Individuals participated in study N=1050

Participants with no pain excluded N=767

Respondents eligible for initial survey

N= 283

Eligible for in-depth assessment (CP) N=73

Results

Results- Pain Prevalence

• The prevalence of chronic pain in the sampled population was 6.95% (73/1050)

• 82.5% of the participants were under some form of treatment

• The shortest and the longest duration of chronic pain at the time of the interview were 7 months and 20 years respectively.

• The median of this variable was 24 months (interquartile range 12-48 months).

• Nineteen percent had constant pain and 78% had intermittent pain.

Results- Pain severity

• 81% had moderate pain (score of 5–7 on NRS scale) and 19% reported severe pain (score of 8–10 ) in their last pain episode. The median NRS score was 6 (IQR: 5-7).

• Of those with CP, 47% were house spouses, 18% were employed full time, 12% were employed part time, 12% were retired and 11% were unemployed.

• Nearly half of (10/22) the individuals who were employed, reported that CP had impacted on their employment status.

Results- Demographics

• A statistically significant relationship was found between CP and gender (p< 0.001) in favour of female participants.

• Other variables including age (i.e., over or under 60 years old), marital status, education and employment status did not show a significant statistical relationship with CP.

• 34 %( 25 person) and 11 %( 8 person) of the respondents had pain in one, two and three location of body respectively and

• Musculoskeletal system (59 cases), gastrointestinal system (18 cases) and head (10 cases) were predominant location of pain.

• Less than 1% of respondents with chronic pain mentioned cancer as a cause of their pain.

Results

• Almost 90% used pharmacological treatments for CP. • The most commonly used analgesic drugs included

NSAIDs (25.3 %), narcotic analgesics (17.2%), beta-blockers (7.5%), cox-2 inhibitors (3.2%), and muscle relaxants (3.2%).

• 37% used non-pharmacological treatment. • The most frequently used techniques included

traditional cultural medicine (similar to complementary medicines in Western countries), acupuncture, thermotherapy, exercise, and massage.

Use of Non-Pharmacologic Tx

Satisfaction with treatments

• Up to 50% of participants were satisfied with their treatments. Of these 44% reported very high satisfaction!

• Ninety three percent (93%) of participants reported they complied with prescribed medications.

• Pain was reported to be under control by 79.5% of the participants, whilst only 18% expressed inadequate management of their pain.

Discussion

• A systematic review by Ospina and Harstall, the average prevalence rate of CP was reported to be 35%. Ospina M, Harstall C. Multidisciplinary pain programs for chronic pain: evidence from systematic reviews. Alberta Heritage Foundation for Medical Research. 2003.

• WHO estimates that 20% of the global population had some degree of CP. Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization study in primary care. JAMA. 1998;280:147-51.

Other countries:• USA 25%, European countries 20% (Norway 30%,

Spain 12%), • Australia ~18.5%, Canada 10%

Discussion

• Our cohort had higher rates of satisfaction with treatment

• They used less non-pharmacological modalities compared to their European counterparts (66%). Breivik et al.

• Comparable use of analgesics and almost similar drugs except for less variety of opioids.

Study limitations

• Subtypes of CP was not investigated; neuropathic, nociceptive or inflammatory pain.

• Limitations in capturing all pain populations. For example, cognitively impaired and nursing home residents could not be included.

• Duration of pain and intensity may have caused different results. We based our study on Breivik’s, which defined the duration of chronic pain in to be at least 6 months, and this well could have had an impact on the prevalence of CP when compared with other studies.

• The timing of the interviews could have had a negative impact as interviews were conducted during the week-days and in working hours, which is likely to include less men or working participants.

Strength• Face-to-face interviews could be regarded as

strength. • Most other studies used a telephone or computer

base survey.

Conclusion

• This is the first study of its kind in Iran. • 6.95% prevalence rate for chronic pain in Shiraz

although significant but was a bit surprising! • In the U.S., 70 million individuals visited doctors

for CP and health services were used for CP 425 million times each year!

• This will have a big impact on health economies and individuals out of pocket costs .

Conclusions

• The ultimate aim of this study was to increase the awareness of the general public, health practitioners and policy makers to this area of great need, and then expand the context to include the significant unmet health issues of this group.

• Larger population base studies at a national level are needed to gain more accurate data on chronic pain and also to explore other aspects of chronic pain including cancer treatment-related chronic pain, neuropathic pain, health related costs, disease burden, barriers to development of pain and palliative services, etc. in Iranian communities.

Conclusions

• The prevalence of pain, is one of the most common symptoms in people dying from both malignant and non-malignant chronic conditions. WHO data

• Pain has been used as an indicator of the need for palliative care services at the end of life. WHO Global Atlas on Palliative Care at The End of Life, http://www.thewhpca.org/resources/global-atlas-on-end-of-life-care

• Despite the myth, the great majority of palliative care need is actually associated with noncommunicable diseases in developing countries.

• Palliative care development follows a public health model developed by the WHO that emphasizes policy, education, medication availability, and implementation. WHO Global Atlas on Palliative Care at The End of Life, http://www.thewhpca.org/resources/global-atlas-on-end-of-life-care

• There are many barriers to achieving each of these components. (Govt.s, health practitioners, consumers, access to medications etc.)

• Policy is seen as the fundamental component, because without it other changes cannot be introduced.

• Cousins and colleagues argued that access to pain relief is a universal and fundamental human right. Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain 2004;112:1–4.

• Brennan argued that access to palliative care is a human right. Brennen F. Palliative care as an international human right. Journal of Pain and Symptom Management 2007; 33(5):494–499.

• Pain and Palliative care is underdeveloped in most of the world, and outside North America, Europe, and Australia, access to quality care is very rare.

• The promise of the demographic dividend is something that this young region too can capture akin to South Asia and South East Asia provided education, employment, health, gender parity can be improved to engage the large numbers of youth

• Ultimately this will necessitate policy as well institutional change to ensure that the latent potential of the “demographic dividend” is realized.

• Collaborative effort is essential to position pain and palliative medicine higher in global and national health agendas.

• Need for clear policies establishing pain and palliative care, use of educational programs to improve teaching pain and palliative medicine, improve access to essential medications needed to deliver pain and palliative care, improved organized service delivery programs in both pain and palliative care

UN Building Sa’adi’s poem

Sa’adi Persian poet in 13th century: “Human beings are members of a

whole,     In creation of one essence and soul.     If one member is afflicted with pain,     Other members uneasy will remain.

     If you've no sympathy for human pain,

     The name of human you cannot retain!”

Thank you!