Costs of moderate to severe chronic pain in primary care patients – a study of the ACCORD Program

Figures & data

Figure 1 Recruitment of pharmacies and patients.

Notes: ^aPharmacy distribution per region (n of recruited pharmacies/total n per region): Mauricie et Centre du Québec, 6/60 (10.0%); Montréal, 18/134 (13.4%); Laval, 13/70 (18.6%); Lanaudière, 8/77 (10.4%); Laurentides, 14/95 (14.7%); Montérégie, 11/77 (14.3%); ^bpatient distribution per region (n of recruited patients per region/total n of patients): Mauricie et Centre du Québec, 44/486 (9.1%); Montréal, 92/486 (18.9%); Laval, 67/486 (13.8%); Lanaudière, 91/486 (18.7%); Laurentides, 117/486 (24.1%); Montérégie, 75/186 (15.4%).
Abbreviation: n, number.

Table 1 Sociodemographic characteristics

	All patients (n=483)	Patients stratified by level of pain disability			P-values
		Mild disabilitya (n=165)	Moderate disabilityb (n=160)	Severe disabilityc (n=158)
Age (years), mean (SD)	59 (13)	61 (13)	58 (12)	57 (11)	0.002
Women, n (%)	326 (67.5)	110 (66.7)	106 (66.3)	110 (69.6)	0.783
Type of insurances, n (%)					0.321
Public (RAMQ)	295 (61.1)	96 (58.2)	95 (59.4)	104 (65.8)
Private	188 (38.9)	69 (41.8)	65 (40.6)	54 (34.2)
Ethnicity (Caucasian),d n (%)	465 (96.3)	161 (97.6)	154 (96.3)	150 (94.9)e	0.457
First language (French),f n (%)	437 (90.5)	151 (91.5)	146 (91.3)	140 (88.6)	0.931
Highest level of education completed,g n (%)					0.664
None or elementary school	132 (27.3)	48 (29.1)	41 (25.6)	43 (27.2)
High-school	170 (35.2)	54 (32.7)	61 (38.1)	55 (34.8)
College-technical school or CEGEP	90 (18.6)	26 (15.8)	30 (18.8)	34 (21.5)
University	87 (18.0)	36 (21.8)	28 (17.5)	23 (14.6)
Civil status,h n (%)					0.034
Married or common law	263 (54.5)	98 (59.4)	91 (56.9)	74 (46.8)
Single	64 (13.3)	15 (9.1)	19 (11.9)	30 (19.0)
Separated/divorced	98 (20.3)	27 (16.4)	33 (20.6)	38 (24.1)
Widowed	57 (11.8)	25 (15.2)	16 (10.0)	16 (10.1)
Annual family income,i n (%)					0.011
<$20,000	128 (26.5)	33 (20.0)	36 (22.5)	59 (37.3)
$20,000–$50,000	188 (38.9)	66 (40.0)	66 (41.3)	56 (35.4)
>$50,000	117 (24.2)	44 (26.7)	42 (26.3)	31 (19.6)
Current work status,j,k n (%)					<0.0001
Full-time job	93 (19.3)	43 (26.1)	33 (20.6)	17 (10.8)
Part-time job	22 (4.6)	9 (5.5)	9 (5.6)	4 (2.5)
Temporary disability	19 (3.9)	2 (1.2)	7 (4.4)	10 (6.3)
Permanent disability	86 (17.8)	16 (9.7)	24 (15.0)	46 (29.1)

Notes:

a Patients in the first BPI tertile (scores ranging from 0–4.3)

b patients in the second BPI tertile (scores ranging from 4.31–6.4)

c patients in the third BPI tertile (scores ranging from 6.41–10.0)

d additional categories were reported: Black; Native American; Hispanic; Asian; and other

e one patient refused to answer

f additional categories were reported: English; Spanish; Italian; Portuguese; German; Arabic; Chinese; Japanese; and Vietnamese

g one and three patients refused to answer in the mild and severe disability groups, respectively

h one patient refused to answer in the moderate disability group

i twenty-two, 16, and 12 patients refused to answer in the mild, moderate, and severe disability groups, respectively

j additional categories were reported: homemaker; student; unemployed; laid off; and volunteer

k two, seven, and four patients refused to answer in the mild, moderate, and severe disability groups, respectively.

Abbreviations: n, number; SD, standard deviation; RAMQ, Régie de l’assurance maladie du Québec; CEGEP, Collège d’enseignement général et professionnel; BPI, Brief Pain Inventory.

Table 2 Clinical and psychosocial characteristics

	All patients (n=483)	Patients stratified by level of pain disability			P-values
		Mild disabilitya (n=165)	Moderate disabilityb (n=160)	Severe disabilityc (n=158)
Duration of pain (years), mean (SD)	12 (11)	11 (11)	11 (11)d	13 (12)	0.186
Duration of pain, n (%)d					0.003
6–12 months	37 (7.7)	17 (10.3)	12 (7.5)	8 (5.1)
13–14 months	1 (0.2)	1 (0.6)	0 (0.0)	0 (0.0)
15–36 months	74 (15.3)	35 (21.2)	23 (14.4)	16 (10.1)
37–48 months	32 (6.6)	6 (3.6)	12 (7.5)	14 (8.9)
49 months or more	338 (70.0)	106 (64.2)	112 (70.0)	120 (75.9)
Frequency of pain in the past 7 days, n (%)					0.000
Always	363 (75.2)	99 (60.0)	125 (78.1)	139 (88.0)
Occasionally	116 (24.0)	62 (37.6)	35 (21.9)	19 (12.0)
Never	4 (0.8)	4 (2.4)	0 (0.0)	0 (0.0)
Average pain intensity in the past 7 days, mean (SD)	6.5 (1.9)	5.5 (1.9)e	6.7 (1.6)	7.3 (1.6)	0.000
Pain functional impact score,f mean (SD)	5.3 (2.2)	2.8 (1.2)	5.5 (0.6)	7.7 (0.8)	0.000
Depression,g n (%)	116 (24.0)	5 (3.0)	38 (23.8)	73 (46.2)d	0.000
Anxiety,g n (%)	193 (40.0)	34 (20.6)	70 (43.8)	89 (56.3)d	0.000
Pain sleep impact score,h mean (SD)	5.1 (2.9)	3.3 (2.6)	5.4 (2.7)	6.6 (2.4)	0.000
Comorbidity index,i mean (SD)	2.5 (1.9)	2.6 (2.0)	2.3 (1.7)	2.5 (1.9)	0.303
Number of self-reported pain diagnoses per patient, mean (SD)	2.5 (1.3)	2.3 (1.2)	2.4 (1.3)	2.9 (1.5)	0.000
Self-reported pain diagnoses, n (%)j
Chronic back pain	309 (64.0)	90 (54.5)	104 (65.0)	115 (72.8)	0.003
Chronic neck pain	186 (38.5)	52 (31.5)	60 (37.5)	74 (46.8)	0.017
Fibromyalgia	114 (23.6)	33 (20.0)	33 (20.6)	48 (30.4)	0.050
Osteoarthritis, arthrosis, and other degenerative osteopathies	293 (60.7)	102 (61.8)	88 (55.0)	103 (65.2)	0.165
Rheumatoid arthritis and other inflammatory osteopathies	55 (11.4)	17 (10.3)	17 (10.6)	21 (13.3)	0.653
Tendinitis, bursitis, capsulitis, and epicondylitis	101 (20.9)	28 (17.0)	35 (21.9)	38 (24.1)	0.275
Visceral pain	74 (15.3)	16 (9.7)	22 (13.8)	36 (22.8)	0.004
Neuropathic pain	88 (18.2)	38 (23.0)	26 (16.3)	24 (15.2)	0.139

Notes:

a Patients in the first BPI tertile (scores ranging from 0–4.3)

b patients in the second BPI tertile (scores ranging from 4.31–6.4)

c patients in the third BPI tertile (scores ranging from 6.41–10.0)

d one missing value

e two missing values

f BPI questionnaire

g Hospital Anxiety and Depression Scale; presence of depression and anxiety disorder is probable when score ≥11

h Chronic Pain Sleep Inventory questionnaire

i Charlson Comorbidity Index

j individuals could report more than one diagnosis.

Abbreviations: n, number; SD, standard deviation; BPI, Brief Pain Inventory.

Table 3 Annual health care resource utilization and productivity losses per patient

Mean (SD)	All patients (n=483)	Patients stratified by level of pain disability			P-value
		Mild disabilitya (n=165)	Moderate disabilityb (n=160)	Severe disabilityc (n=158)
Health care resources utilization per patient
Number of hospitalization days
All causes	1.9 (9.9)	1.1 (5.8)	3.2 (15.1)	1.5 (5.5)	0.146
Pain-related as possible cause	1.1 (8.3)	0.7 (5.6)	1.8 (12.6)	0.8 (4.2)	0.468
Number of physician visits
Primary care	0.4 (2.7)	0.2 (1.3)	0.4 (2.3)	0.6 (3.9)	0.423
Specialists	1.1 (4.4)	0.8 (3.8)	1.4 (5.5)	1.1 (3.7)	0.449
Number of emergency room visits	0.9 (1.6)	0.6 (1.3)	0.9 (1.8)	1.1 (1.7)	0.046
Number of physician visits at emergency
Primary care	0.2 (1.3)	0.2 (1.3)	0.2 (1.3)	0.3 (1.2)	0.645
Specialists	0.9 (3.3)	0.4 (1.9)	1.2 (4.0)	1.1 (3.7)	0.085
Number of outpatient physician visits
Primary care	4.8 (4.9)	4.4 (3.9)	4.1 (4.1)	6.0 (6.3)	0.001
Specialists	2.1 (3.1)	1.9 (2.7)	1.8 (2.7)	2.8 (3.8)	0.008
Number of outpatient tests and interventions
All	10.7 (7.5)	10.0 (6.9)	10.6 (8.1)	11.6 (7.3)	0.136
Pain-related	1.4 (1.8)	1.2 (1.6)	1.5 (1.9)	1.4 (1.8)	0.322
Number of complementary health care provider visits
Psychotherapists	2.7 (13.4)	1.7 (9.5)	2.9 (14.7)	3.5 (15.4)	0.451
Physiotherapists	40.3 (90.1)	31.3 (75.5)	45.3 (98.0)	44.6 (95.6)	0.291
Massage therapists	13.5 (48.8)	9.0 (34.3)	15.1 (49.6)	16.5 (59.6)	0.336
Occupational therapists	5.4 (30.7)	4.4 (30.6)	6.4 (29.4)	5.4 (32.3)	0.848
Acupuncturists	4.3 (21.3)	4.7 (19.9)	4.2 (18.6)	4.0 (25.1)	0.946
Osteopaths	4.2 (18.0)	6.4 (22.8)	3.6 (16.8)	2.7 (12.8)	0.159
Chiropractors	4.2 (18.9)	6.3 (23.8)	2.3 (12.4)	3.9 (18.5)	0.157
Total	74.6 (135.5)	63.9 (110.8)	79.7 (142.7)	80.7 (150.8)	0.454
Number of prescribed pain-related medicationsd	3.9 (2.0)	3.4 (1.9)	4.1 (2.0)	4.2 (2.0)	0.000
Number of over-the-counter pain-related medicationsd	1.5 (1.6)	1.5 (1.6)	1.5 (1.7)	1.5 (1.6)	0.897
Annual productivity losses per patient
Number of absenteeism dayse	57.3 (106.3)	32.9 (83.4)	54.9 (104.7)	85.3 (122.0)	0.000
Number of presenteeism daysf	12.1 (36.0)	8.7 (24.1)	19.0 (46.7)	8.7 (33.0)	0.012
Total number of workdays lost	69.4 (111.3)	41.6 (86.3)	73.9 (114.5)	94.0 (124.7)	0.000

Notes:

a Patients in the first BPI tertile (scores ranging from 0–4.3)

b patients in the second BPI tertile (scores ranging from 4.31–6.4)

c patients in the third BPI tertile (scores ranging from 6.41–10.0)

d including analgesic and medication to treat side effects of analgesics

e individuals with full- or part-time jobs, as well as those on temporary or permanent disability were included. A null value was computed for all other individuals

f only individuals answering yes to the question “Do you currently have a paid job?” and those having a full- or part-time job were included. A null value was computed for all other individuals.

Abbreviations: SD, standard deviation; n, number; BPI, Brief Pain Inventory.

Table 4 Crude annual direct health care costs and productivity costs (CAD dollars) per patient

Mean (SD)	All patients (n=483)	Patients stratified by level of pain disability			P-values
		Mild disabilitya (n=165)	Moderate disabilityb (n=160)	Severe disabilityc (n=158)
Direct health care costs
Hospitalizations
All hospitalization costs, except physician visits	1,908 (9,877)	1,148 (5,849)	3,117 (15,080)	1,480 (5,583)	0.021
Pain-related hospitalization costs	1,102 (8,304)	739 (5,555)	1,763 (12,610)	810 (4,213)	0.043
General practitioner visits	14 (98)	9 (47)	13 (91)	22 (137)	0.004
Specialist visits	114 (321)	106 (307)	138 (380)	99 (267)	0.508
Total costs	2,036 (10,137)	1,262 (6,053)	3,266 (15,404)	1,600 (5,878)	0.030
Emergency room visits
Emergency room costs	250 (481)	179 (369)	267 (553)	308 (498)	0.150
General practitioner visits	8 (44)	5 (33)	6 (42)	13 (55)	0.001
Specialist visits	62 (289)	43 (260)	65 (262)	78 (341)	0.455
Total costs	320 (686)	227 (528)	338 (753)	399 (752)	0.148
Outpatient medical consultations
Primary care visits	231 (247)	211 (205)	204 (233)	278 (291)	0.129
Specialist visits	163 (240)	137 (195)	144 (222)	209 (290)	0.094
All outpatient tests and interventions	145 (170)	132 (163)	149 (186)	152 (161)	0.699
Pain-related tests and interventions	66 (102)	50 (80)	75 (116)	72 (105)	0.115
Total costs	604 (541)	531 (437)	573 (561)	712 (602)	0.048
Complementary health care provider visits
Psychotherapists	257 (1,276)	160 (902)	279 (1,400)	335 (1,466)	0.103
Physiotherapists	2,337 (5,231)	1,818 (4,382)	2,626 (5,688)	2,586 (5,546)	0.528
Massage therapists	781 (2,830)	521 (1,992)	873 (2,876)	959 (3,457)	0.181
Occupational therapists	343 (1,944)	281 (1,937)	405 (1,861)	345 (2,043)	0.607
Acupuncturists	249 (1,235)	274 (1,153)	243 (1,077)	230 (1,455)	0.875
Osteopaths	339 (1,426)	507 (1,801)	288 (1,326)	216 (1,011)	0.043
Chiropractors	198 (899)	299 (1,131)	108 (587)	185 (880)	0.013
Total costs	4,505 (8,115)	3,860 (6,706)	4,822 (8,599)	4,856 (8,924)	0.640
Prescribed analgesics and medication to treat side effects of medication	1,963 (2,978)	1,304 (1,728)	1,979 (3,029)	2,635 (3,728)	<0.001
Over-the-counter analgesics and medication to treat side effects	136 (601)	150 (709)	150 (708)	108 (275)	0.341
Total direct health care costs	9,565 (13,993)	7,334 (9,276)	11,128 (19,131)	10,311 (11,501)	0.008
Productivity costs
Absenteeism	5,052 (9,429)	3,068 (7,677)	5,084 (9,743)	7,091 (10,339)	0.082
Presenteeism	2,020 (6,013)	1,455 (4,027)	3,171 (7,804)	1,445 (5,511)	0.057
Total productivity costs	7,072 (11,716)	4,523 (8,951)	8,254 (13,386)	8,536 (12,077)	0.158
Total overall costs	16,636 (19,182)	11,857 (13,685)	19,382 (23,228)	18,847 (18,734)	<0.001

Notes:

a Patients in the first BPI tertile (scores ranging from 0–4.3)

b patients in the second BPI tertile (scores ranging from 4.31–6.4)

c patients in the third BPI tertile (scores ranging from 6.41–10.0).

Abbreviations: CAD, Canadian; SD, standard deviation; n, number; BPI, Brief Pain Inventory.

Table 5 Adjusted annual direct health care costs and productivity costs (CAD dollars) per patient

Mean (95% CI)	Mild disabilitya (n=165)	Moderate disabilityb (n=160)	Severe disabilityc (n=158)	P-values
Direct health care costs
Hospitalization
All-cause hospitalizations	897 (415; 1,380)	2,857 (1,348; 4,365)	2,021 (849; 3,193)	0.012
Pain-related hospitalizations	326 (146; 507)	1,700 (707; 2,693)	883 (224; 1,542)	0.001
Emergency room visits	228 (137; 319)	339 (202; 476)	400 (238; 563)	0.149
Outpatient consultation visits	532 (441; 622)	574 (475; 673)	713 (589; 837)	0.048
Complementary health care provider visits	4,165 (2,553; 5,776)	4,279 (2,638; 5,921)	4,345 (2,665; 6,024)	0.989
Prescribed analgesics	1,428 (1,143; 1,713)	1,976 (1,589; 2,363)	2,330 (1,848; 2,812)	0.004
Over-the-counter analgesics	112 (74; 150)	138 (91; 185)	116 (76; 155)	0.646
Total	7,374 (5,819; 8,930)	10,524 (8,383; 12,665)	9,546 (7,502; 11,590)	0.051
Productivity costs
Absenteeism	2,320 (1,179; 3,460)	3,175 (1,587; 4,763)	4,922 (2,449; 7,395)	0.108
Presenteeism	826 (368; 1,284)	1,761 (841; 2,681)	300 (130; 469)	0.000
Total	3,005 (1,587; 4,422)	5,083 (2,647; 7,519)	5,385 (2,789; 7,981)	0.194
Total direct health care and productivity costs
Including all cause hospitalizations	12,913 (10,534; 15,292)	17,970 (14,782; 21,159)	17,292 (14,075; 20,510)	0.024
Including pain-related hospitalizations	12,118 (9,844; 14,393)	18,278 (14,909; 21,648)	19,216 (15,538; 22,894)	0.001

Notes:

a Patients in the first BPI tertile (scores ranging from 0–4.3)

b patients in the second BPI tertile (scores ranging from 4.31–6.4)

c patients in the third BPI tertile (scores ranging from 6.41–10.0).

Abbreviations: CAD, Canadian; CI, confidence interval; n, number; BPI, Brief Pain Inventory.

Table S1 Hospitalization codes related or possibly related to chronic pain

• Adhesive capsulitis of shoulder

• Algoneurodystrophy, unspecified

• Arthritis, unspecified

• Articular ankylosis

• Articular ankylosis – knee joint

• Carpal tunnel syndrome

• Cervicalgia

• Chronic intractable pain

• Chronic salpingitis and oophoritis

• Coxarthrosis, unspecified

• Endometriosis of uterus

• Endometriosis, unspecified

• Fibromyalgia

• Gonarthrosis, unspecified

• Gout, unspecified

• Idiopathic gout – elbow joint

• Idiopathic gout – hand joints

• Irritable bowel syndrome with diarrhea

• Irritable bowel syndrome without diarrhea

• Lateral epicondylitis

• Low back pain

• Osteoarthritis, unspecified

• Other cervical disc displacement

• Other dorsalgia

• Other specified arthrosis

• Other specified disorders of bone – leg

• Other specified intervertebral disc displacement

• Other specified spondylopathies – cervical region

• Pain in limb – scapular region

• Radiculopathy – dorsal region

• Rheumatoid arthritis, unspecified

• Rotator cuff syndrome

• Spinal instabilities – lumbar region

• Spinal stenosis – cervical region

• Spinal stenosis – lumbar region

• Spondylosis, unspecified – lumbar region

Table S2 Documented analgesics

Therapeutic class	International common denomination
Anticonvulsants
Carboxylic acid derivatives	Valproic acid
Gamma-aminobutyric acid analogs	Gabapentin, Pregabalin
Iminostilbene	Carbamazepine, Oxcarbazepine
Other anticonvulsants	Divalproex, Lamotrigine, Topiramate
Antidepressants
Selective serotonin reuptake inhibitors	Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Trazodone
Serotonin and noradrenaline reuptake inhibitors	Duloxetine, Venlafaxine
Tricyclic and tetracyclic antidepressants	Amitriptyline, Clomipramine, Desipramine, Doxepin, Imipramine, Maprotiline, Mirtazapine, Nortriptyline, Trimipramine
Other antidepressants	Bupropion
Antiretroviral	Acyclovir, Famciclovir, Valacyclovir
Disease-modifying antirheumatic drugs	Auranofin, Aurothioglucose, Aurothiomalate, Azathioprine, Chloroquine, Cyclosporine, D-penicillamine, Hydroxychloroquine, Leflunomide, Methotrexate, Sulfasalazine
Muscle relaxants
Benzodiazepine	Diazepam, Tetrazepam
Carbamic acid derivatives	Methocarbamol
Centrally acting myorelaxants	Cyclobenzaprine, Tizanidine
Gamma-aminobutyric acid derivatives	Baclofen
Other muscle relaxants	Thiocolchicoside
Nonsteroidal antiinflammatory
Acetic acids	Diclofenac, Etodolac, Indomethacin, Ketorolac, Nabumetone
Acetylsalicylic acid
Coxibs	Celecoxib
Fenamates	Meclofenamate, Mefenamic acid
Oxicams	Meloxicam, Piroxicam
Propionic acids	Fenoprofen, Flurbiprofen, Ibuprofen, Ketoprofen, Naproxen, Oxaprozin
Opioids
Agonist–antagonist derivatives	Buprenorphine, Butorphanol, Nalbuphine, Pentazocine
Antagonists	Naloxone
Benzomorphan derivatives	Pentazocine
Centrally acting analgesics	Tramadol
Meperidine-like agonists	Fentanyl, Meperidine
Methadone-like agonists	Methadone, Propoxyphene
Morphine-like agonists	Codeine, Hydrocodone, Hydromorphone, Levorphanol, Morphine, Oxycodone, Oxymorphone
Natural cannabinoids	Tetrahydrocannabinol, Cannabidiol
Synthetic cannabinoids	Dronabinol, Nabilone