Time since diagnosis, treatment pathways and current pain status: a retrospective assessment in a back pain...

The purpose of this study is to report on long-term treatment patterns in a back pain population and to consider whether these may be considered as reflective of under-treatment of pain or poor pain control.

Data are from a commissioned recontact SELECT survey of persons who had previously reported experiencing pain in the 2010 National Health and Wellness Survey. The analysis covers five countries: the UK, France, Spain, Germany and Italy. It is restricted to patients who reported moderate or severe pain in the last 3 months and who were judged to be experiencing back pain from the pain conditions reported. A total of 1018 subjects met the back pain criteria. Of these, 738 had their back pain initially diagnosed by a physician. It is this latter group that is the focus for the analysis. Subjects were further allocated to categories to assess potential pain chronicity and the intensity and self-limiting aspects of pain experience.

Irrespective of the pain classification used, 56.10% of subjects in this back pain population report their first physician diagnosis of pain as occurring at least 6 years ago. At the same time 36.81% report experiencing severe pain in the last 3 months and 63.69% moderate pain. Overall, 53.11% of respondents are assessed as experiencing probable chronic pain and 24.12% as possible chronic pain. Among those experiencing probable chronic pain, 61.48% were diagnosed with back pain more than 6 years ago. In addition, 43.22% of respondents found the impact of pain on daily activities to be severely limiting and 22.63% found it to be moderately limiting. The majority of subjects, whether they were diagnosed and treated initially by primary care or another physician specialty, apparently experience no change in their treatment regimen. The absence of treatment change is 69.03% in the case of those experiencing severe pain and 84.89% in the case of those with moderate pain (p < 0.05).

The NHWS is an internet survey, as a self-report there is no separate validation of pain experience reported; as subjects are asked to recall pain and treatment experience there is the possibility of recall error and bias.

Two features of this analysis stand out: (i) time since first diagnosis of pain for those currently experiencing severe or moderate back pain and (ii) the 'inertia' that appears to characterize long-term treatment decisions. Irrespective of current pain status, 70% or more of those experiencing current severe or moderate pain report no change from their initial treating physician or no change in prescription once referred to a pain specialist. This occurs over an extended time frame. Whether this should be interpreted as a failure in pain management is a moot point. The fact remains, however, that despite time since first diagnosis subjects not only currently experience severe or moderate pain but a substantial proportion may be expected to continue.