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First EFIC® Symposium

Societal Impact of PainMay 4th & 5th 2010

Hotel Dolce La Hulpe, Brussels

ABSTRACTS& PROGRAM

SIPSocietal Impact of Pain

This symposium is organized by EFIC® and generously sponsored byGrünenthal GmbH

www.EFIC.org

© 2010, EFIC®

This booklet is published supporting the symposium first EFIC® Symposium "Societal Impact ofPain", May 4th & 5th 2010. You can copy, download or print the content of this booklet for your own use provided that suitable acknowledgment of EFIC® as well as to the participating authorsas source and copyright owner is given. All requests for public or commercial use and translationrights should be submitted to [email protected].

EFIC® (European Federation of IASP ChaptersMedialaan 241800 VilvoordeBelgiumhttp://www.efic.org

Meeting LogisticsR EventsE-mail: [email protected]: + 32 3 544 7880 Tel: + 32 473 291 361

MDEON Visa number:10/V1/2450/02561710/V2/2450/001549

Sponsor

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Graphic design: Petra Eich, Grünenthal



ABSTRACTS& PROGRAM


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Dear Madam,Dear Sir,

As you may know, EFIC® is the federation of the most relevantscientific societies of healthcare professionals for the studyof pain in Europe.

Recent data show that a big group of pain patients is not adequately treatedbecause pain is not fully recognized as an important health issue by many of thenational health care systems.At the same time in many countries some very interesting projects have beeninitiated investigating the economic factors related to the burden of pain to patientsand the society. Unfortunately the knowledge gained and management instrumentsdeveloped locally are still sparsely shared amongst health care authorities andstakeholders throughout Europe. With this in mind EFIC® is convinced of theimportance to discuss the ‘Societal Impact of Pain’ with authorities, insurances,budget holders and strategic decision makers within national health care systems.

For this reason EFIC® would like to invite you to participate in the first symposiumon this subject aiming to describe problems and delivering facts around prevalence,demographics, quality measurement, costs and resources.

Yours sincerely

Prof. Giustino Varrassi, MD, PhD, FIPPPresident

European Federation of the IASP Chapters (EFIC®)

Medialaan 24 | 1800 Vilvoorde | Belgium | http://www.efic.org

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The European Federation of IASP chapters

(EFIC®) is a multidisciplinary professional

organization in the field of pain science

and medicine, made up of the 34 European

Chapters of IASP (International Associa-

tion for the Study of Pain).

Established in 1993, by Prof. Ulf Lindblom,

the EFIC® represents 34 countries and

close to 20,000 scientists, physicians,

nurses, physiotherapists, psychologists

and other healthcare professionals across

Europe, who study pain and treat patients

in pain.

Mission Statement

The European Federation of IASP Chapters

(EFIC®) was formed by the presidents of

the European Chapters at a joint meeting

held at the time of the World Congress

on Pain, in Paris in August, 1993.

Aims

The objectives of the EFIC® are in general

those of IASP, i.e. to promote research,

education, and the clinical management

of pain.

The specific aim is to create a forum for

European collaboration on pain issues and

to encourage communication at a Euro-

pean level between IASP Chapters, and

also with other bodies interested or

involved in the fields of pain research and

therapy such as the European societies

or federations of medical specialities (ana-

esthesiology, neurology, headache, pallia-

tive care etc.), institutions of the European

Community, European and national educa-

tors and legislators.

Examples of pain issues that may be

dealt with by EFIC®:

• The epidemiology of acute and chronic

pain in Europe.

• The availability of pain treatment facili-

ties.

• The interface between patient needs

and treatment facilities.

• The recognition of differences in thera-

peutic strategies and pain education

within Europe.

• The harmonisation of such differences.

• Review of existing curricula and plans

for training of pain specialists (it might

be desirable to develop a European aca-

demy to accredit pain specialists, possi-

bly by examination).

• Setting standards for diagnosis and

treatment of chronic pains of different

types and mechanisms.

Constitution

The affairs of EFIC® are conducted by its

Council, which consists of the Presidents

of the European IASP Chapters, and five

elected officers who form the Executive

Board.

The Council meets once a year while the

Board manages affairs between meetings.

EFIC® is established as a charitable foun-

dation in Belgium.

EFIC's position in relation to IASP

The bylaws of the IASP (section V) provide

that national Pain Societies and Associati-

ons may constitute Chapters of the IASP

in their country.

The EFIC® acts as a European grouping of

these Chapters of the IASP, so that they

may work together while allowing for the

socio-cultural diversity of Europe. Many of

ABOUT EFIC®

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the societies have a large percentage of

members who are not members of IASP;

they are, none-the-less, members of EFIC®

and will benefit from the wider

perspectives offered by a trans-national

organisation.

Specific programmes

EFIC® co-operates in the organisation of

Congresses, such as those in Verona, Italy,

in May 1995 in Barcelona, Spain, in 1997,

in Nice, France in 2000, in Prague, Czech

Republic in 2003, in Istanbul, Turkey 13-

16 2006, Lisbon, Portugal in 2009 and

upcoming in Hamburg, Germany in Sep-

tember 21-24 2011.

EFIC® produces an electronic newsletter

which is distributed by an email database

list to the Chapters and to all their mem-

bers and is available on the website and is

involved with the production of the Euro-

pean Journal of Pain.

Under EFIC® auspices, Task Forces are

working on aspects of pain research and

management, and their findings will be

used to improve education and training

throughout Europe.

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General Information All speakers are requested to deliver their presentation 30 minutes prior to each session blockat the latest to R-Events. All presentations submitted to R-Events by the specified advancedeadline are pre-loaded on to the session room computer. If you did not submit your presentationin advance bring your presentation on a USB/flash drive and R-Events staff will assist you withloading your presentation.

LanguageThe meeting language for presentations, workshops and discussions is English.

The venue: Dolce La HulpeHotel Dolce La Hulpe135, Chaussée de Bruxelles, 1310 La HulpeBELGIUMPhone: +32 (0)2 290 98 00http://www.dolce-la-hulpe-brussels-hotel.com

Check In 3:00 p.m. Check Out 12:00 p.m.

Left LuggageOnce you have checked out please leave your luggage with the concierge who will store it in a secure room. Please ask at the concierge desk or ask a member of the hospitality staff for assistance.

Hospitality DeskThere will be a manned hospitality desk in the main Lobby throughout the sym-posium. Please ask any of the hospitality staff if you have any questions or needany assistance throughout your stay. If you require assistance for any travelneeds, please see Randa Jane Becker at the registration desk or contact hervia email at [email protected] or cell phone +32 473 291 361.

Symposium Evening ProgramThe Symposium evening program and dinner will be held in the Redwood Room, which is on thefirst floor above the lobby.

Hotel Information

Accommodation • Free Wireless High Speed Internet Access • Voice over IP Phone • Newspapers available

Technology • Free Wireless Internet Access throughout Property• IT & AV Staff Onsite• Business Centre• Sm@rt Print

Breakfast and LunchBreakfast will be served in the Argan Restaurant, which is located on the ground floor.

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Floor planGROUND FLOOR/REZ-DE-CHAUSSÉE

FIRST FLOOR/PREMIER ÉTAGE

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Floor planCONFERENCE CENTRE/MEETING ROOMS

Ground Floor

First Floor

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Second Floor

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10:00 Registration

Chairmen: Albrecht Kloepfer, Giustino Varrassi

13:00 Opening Giustino Varrassi

13:05 Welcome Laurette Onkelinx

13:30Can pain be helpful as a quality indicator for health care systems?

Alberto Grua

13:45Chronic pain: a disease without aname

Serdar Erdine

14:15The Need For A Whole Systems Perspective

Ceri Philips

14:45The impact of pain according to consumers and patients; results of a survey in big 5 EU countries

Paul Langley

15:15 Break

15:30 Health and Pain in the European Union Isabel De La Mata

16:00Interventional therapeutic strategiesfor the treatment of pain

José De Andrés

16:30 Innovation; pain or value Meindert Boysen

17:00The informational gap between physicians and their patients.

Lise Rochaix

17:30Therapeutic strategies for thetreatment of pain

Paolo Daniele Siviero

18:00Are we adequately equipped to asses pain therapies

Ken Paterson

18:30 Discussion

18:30 End plenum

20:00 Dinner

22:00 Dinner end

Draft program - May 4th 2010Auditorium Baobab

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Draft program - May 5th 2010Parallel Workshops

08:30 Workshop 1

Prevalence and epidemiology

Chairman: Per Hansson

Secretary: Alain Serrie

Moderator: Isabelle Durand Zaleski

Reporter: Narinder Rawal

08:30 Chronic pain in Austria Wilfried Ilias

08:50 Discussion based on the previous presentation

09:00Prevalence of neuropathic pain in Poland.

Jan Dobrogowski


09:30Results of a literature review on the epidemiology of chronic pain in the EU

Jos Kleijnen


10:00 Coffee break

10:15 Pain in oncology Ana Casas


10:45Prevalence and socio-economic impact of pain in Portugal

José Castro Lopes


11:15Analyses of types and costs of pain - based on 6 million insured persons

Cornelius Erbe


11:45 Discussion and consensus on a common statement

12:00 Lunch

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08:30 Workshop 2

Evidence in pain therapy from a societal perspective

Ken Paterson

Secretary: Wil Toenders

Moderator: Yves Henrotin

Reporter: Marja Kuijpers

Painlessly into the package: incorporating pain treatment innovations

Martin van der Graaff

Evidence in pain or pain in Evidence?

Norbert Schmacke

Practice of benefit assessment of pain relieving medications

Matthias Perleth

Pain undertreat¬ment in oncological patients

Giovanni Apolone

"WHO Treatment Guidelines onPain: Processes, Status, Challenges"

Barbara Milani

Measuring Functionality as Treatment Outcome in Low Back Pain

Thomas R. Tölle

12:00 Lunch


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08:30 Workshop 3

Impact of pain on the society

Secretary: Gottfried Endel

Moderator: Albrecht Kloepfer

Reporter: Norman Evans

Citizens rights for pain treatment in Italy

Antonio Gaudioso

The impact of pain from the patient perspective

Joana Gabriele Muñiz

Pain and Rehabilitation Roberto Casale

Pain and family Werner Kerschbaum

Pain management in practice Michel Vanhalewyn

Charter of Rights for people living with Chronic Pain

Gina Plunkett

Quality of`life after pain treatment in patients with fybromialgia

Emilia Altarriba

12:00 Lunch


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08:30 Workshop 4

Health economic models inpain treatment

Chairman: Eli Alon

Secretary: Francis Fagnani

Moderator: Christoph Vauth

The Social Economic Costs ofChronic Pain in Spain.

Renata Villoro

How to asses the economiccost of pain in Denmark?

Morten Andreas Hjulsager

Issues in the Health TechnologyAssessment of Treatments forPain

Ailsa Brown

Why do we need an ICD10 code for chronic pain?

Reinhard Thoma

Overview of objectives and me-thodology of ongoing real worldstudies

Ian Power

Medico-legal medicine and economic challenges in painmedicine

Eric Jensen

Monitoring of pain therapy inlocal health-care unit

Pietro Giusti

12:00 Lunch


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08:30 Workshop 5

Costs related to painChairman: Hans-Georg Kress

Co chairman: Bernard Avouac

Secretary: Ad Rietveld

Moderator: Livio Garattini

The costs of musculoskeletalpain: the need for priority services

Paul J. Watson

The social cost of painful neuropathy in the 21st century

Magdi Hanna

Pharmacoepidemiologicalaspects on the costs of pain

Eva Zebedin-Brandl

What can we learn from insurance data on pain, facts and costs?

Jacob Hofdijk

Measuring the value of pain in economic evaluation

Paul Kind

Project design to analyse thefacts on pain related cost inSweden

Marcelo Rivano-Fischer

12:00 Lunch


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08:30 Workshop 6

Light house projects (“best practice”)

Chairman: Mary Baker

Secretary: Günter Danner

Societal benefit of multidiciplinary rehabilitation in chronic non-malignant pain patients.

Villy Meineche Schmidt

Pathways of Care for pain Beverly Collett

The Italian experience Guido Fanelli

Back Pain Survey in Styria – Data basis for a paradigm change?

Ewald Gspurning

Benefits of self-care programs in pain for patients

Sergi Blancafort

Role of Regione Toscana in supporting improvements in pain treatment

Galileo Guidi

“Hospital Sin Dolor” project in SpainJosé María Muñoz y Ramón

Information underload: the importance ofdata collection in service development

Benjamin Ellis

12:00 Lunch


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Chairmen: Albrecht Kloepfer, Giustino Varrassi

Report of the workshops

13:00Report on workshop 1 Prevalence and epidemiology

Narinder Rawal

13:00Report on workshop 2 Evidence in pain therapyfrom a societal perspective

Marja Kuijpers

13:00Report on workshop 3 Impact of pain on the society

Norman Evans

13:00Report on workshop 4 Health economic modelsin pain treatment

13:00 Report on workshop 5 Costs related to pain

13:00Report on workshop 6 Light house projects(“best practice”)

14:00 The future of cooperation’s in pain therapyNorbert Klusen

14:30Developing a National Service Framework forchronic pain

Pete MacKenzie

15:00 Discussion & summary

16:00 end

Auditorium Baobab

Workshop 1 Prevalence & epidemiology

Measuring the magnitude of the problemIn some cases pain may become intractable and develop into a condition called chronic pain, inwhich pain is no longer considered a symptom but an illness of itself. These cases often developto having a high budget impact. Some sources estimate pain being one of the top 10 diseasesimpacting health care budgets.In order to make valid decisions regarding policy and budgets managers need to have a validdata base. This workshop aims to give an overview on the possibilities and short comings of thesources on prevalence and epidemiology currently available for strategic decision making onpain related budgets.

Workshop 2 Evidence in pain therapy from a societal perspective

How to generate evidence, relevant to budget holders and policy makers?For most treatments efficacy can be seen as a valid outcome. As pain mostly appears as amajor symptom in many medical conditions, while being considered as highly subjective, pain re-lated outcomes are often hard to translate in valid evidence for decision making by health au-thorities. The symptomatic and personal nature of pain makes it a challenge for health care au-thorities to reflect pain and its treatment in their decisions.

Workshop 3Impact of pain on the society

Pain is not just a clinical or individually relevant problem. Beyond health policy pain plays a seriousmacro-economic role in our society, for example due to pain resulting in reductions in productivity,absenteeism and early retirement. At the same time acute pain, chronic pain and pain in palliativecare are so present in society that authorities are frequently confronted with the need to takeadequate decisions.The workshop "Impact of Pain on society" aims to investigate the broad range social implicationsof pain on society leading to strategic decisions, not only from a health policy perspective butalso in other fields of politics like business, employment or social environment.

Workshop 4Health economic models on pain treatment

Health economic models on the functioning of the health care system and the private and socialcauses of health-affecting behaviours are a frequently used as a base for decision making. Fewmodels for pain are available. This leads to a variety of questions like:

• How to measure the impact of pain therapeutic innovations in pain care? • Can we learn from health economic models in pain from other areas include extensive govern-

ment intervention?

This workshop aims to investigate the opportunities and possibilities of Health economic modelsin pain therapy.

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Workshop 5Cost related to pain

Chronic pain and the measurement of its impact on healthcare and societyPain is a symptom that accompanies many diseases. As such pain is often treated in the contextof these co-morbidities. In most EU-countries decision makers on health care budgets usually do not have access torobust data showing the societal impact of pain. Pain and chronic pain as such are seldom re-flected in the health care budgets and policy making. The lack of attention to the management ofcost and translation of quality outcomes related to pain potentially leads to an under estimationof its consequences for the quality of life of patients, its contribution to the healthcare budgetand its impact on society.

Workshop 6 Light house projects (“best practice”)

Large scale longitudinal data on pain outcomes available to decision makers and policy makersare rare. In several countries projects have been initiated aiming to gain insight in the issues re-lated to pain and costs caused by pain. These are expected to deliver the facts and figures likeprevalence, demographics, quality measurement, cost and resources related to the impact ofpain on society.This workshop intends to share the insight of some light house projects in order to create a plat-form for sharing “best practices”.

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Background information on speakers and workshop chairpersons, moderators, secretaries, and workshop

reporters in alphabetical order of their last name



Hotel Dolce La Hulpe, Brussels


Professor Eli Alon, M.D.Professor of Anesthesiology University, Zurich

• Professor of Anesthesiology University ofZurich

• Director Pain Control Unit Beder Str 80,8002 Zurich, Switzerland

• Consultant for Pain Medicine Zurich Uni-versity Hospital

• Past-President of the Swiss Association forthe Study of Pain SGSS

• Executive Board Member of The EuropeanFederation of IASP Chapters EFIC

• Former Chairman Department of Anesthe-siology Regional Hospital of Lugano,Switzerland

• Lecturer at the University of Zurich and atthe University Hospital

• Organizer and invited speaker in National,European and International Congresses

• Author of books, proceedings, original andreview articles, book chapters, and ab-stracts.

Chronic pain: a disease in its own rightPain is a major healthcare problem in Europe.Although acute pain may be considered asymptom of diease or injury, chronic andpersistent pain is a specific healthcareproblem, a disease on its own right.Acute pain, such as that following trauma orsurgery, constitutes a signal to a conciousbrain about the presence of noxious stimuliand/or ongoing tissue damage. This acute painsignal is useful and adaptive, warning theindividual of danger and the need to escape orseek help. Acute pain is a direct outcome of thenoxious event, and is reasonable classified asa symptom of underlying tissue damage ordisease. However, in many patients pain

persists long after its usefulness as an alarmsignal has passed, and indeed, often long afterthe tissue damage has healed. Chronic pain inthese patients is probably not directly relatedto their initial injury or disease condition, butrather to secondary changes including onesthat occur in the pain detection system itself.In addition to being due to differentphysiological mechanismus than acute pain,chronic pain often sets the stage for theemergence of a complex set of physical andpsychosocial changes that are an integral partof the chronic pain problem and that addgreatly to the burden of the pain patient.

Eli Alon

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Emília Altarriba AlberchPresident of the Foundation of Fibromyalgiaand Chronic Fatigue Syndrome Patients(Barcelona, Spain)

PAIN AND QUALITY OF LIFE IN PATIENTSWITH FIBROMYALGIA

The data of the Spanish Association of Painshow that 10 % of the population of Spainsuffers from chronic pain, with nearly half ofthis group suffering daily. The situation isserious taking into account that it affectsconsiderably patient’s personal, family, socialand labor life.

In the case of Fibromyalgia (FM), the situationis particularly worrying for several reasons.First of all, the pain as a symptom of a diseasetransforms in FM into a disease in its ownright, with a considerable loss of life quality,aggravated by the lack of information,awareness and recognition, which reduces, inmany cases, the rights of FM affected peopleas patients and as citizens.

A typical profile of FM patient is a woman of 35-45 years old, out of work due to diseasefluctuations, searching for medical solutions toher pain and with psychological devastation,family problems and a very negative per-ception regarding respect, interest, andcomprehension of her disease. All the abovementioned factors place FM patients in thegroup at high risk of social exclusion.

To improve the situation, it has been crucial tocreate a patients’ social network of FMassociations with the aim to inform andsupport patients, vindicate their rights, provideservices, and change minds. With this purpose was established theFoundation of Fibromyalgia and Chronic FatigueSyndrome Affected Patients, which assists inthe process of improving the quality of life ofpatients and carries out activities directedtowards information dissemination, awarenessincreasing, training, and research promotion.

The program Foundation FF and Scienceconsists of trainings for professionals, such asan annual conference "Dr. Broggi Moses", andtrainings for trainers; it also includes projectsto encourage and support research, such asDNA bank for genetic investigation andresearch awards. The program Foundation FFand Society is directed towards increasingawareness and social vindication, such as theannual Manifesto, supporting the associations,with the creation of a network of more than130 patients’ associations, organizing anannual conference “Codo con Codo”.

According to the survey made by theFoundation FF among 130 FM associations in2008, the majority of FM patients believe thatthe most effective actions to improve the lifequality should be considered correct and earlydiagnosis; good palliative treatment of pain;rigorous protocols on disease treatment;respect to patients on the part of professionalsand institutional officials; expanding jobopportunities; recognition of social rights andgreater social awareness; better coordinationbetween associations and authorities;encouraging research of new treatments andpossible cure. It means that an adequateapproach and recognition of the disease canimprove patients’ quality of life. Still, this couldbecome possible when all stakeholders - health professionals, government, society,associations and patients themselves – startworking together to develop specific actionprograms to reduce impact of the disease thatis considered to be PAIN paradigm.

Emília Altarriba Alberch

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Prof. Jose De Andrés MD, PhD, FIPPQualified from the School of Medicine of theValencia University.

Current Positions and responsibilities:• Associate Professor of Anaesthesiology of

the Valencia University School of Medicine.• Chairman of Anaesthesia , Critical Care and

of the Multidisciplinary Pain ManagementDepartments in the Valencia University Gen-eral Hospital (Valencia, Spain).

• European Society of Regional Anesthesia andPain Therapy (ESRA): Treasurer, member ofthe scientific committee and councillor ofSpain in the board of directors.

• European Federation of IASP Chapters (EFIC):Councillor of Spain in the European council.

• Spanish Pain society (IASP Chapter): Directorof continuous medical education programme

• President of “Foundation for study and treat-ment of pain of the Valencian community”

Member on editorial boards of national andinternational journals in the field of RegionalAnaesthesia and Pain MedicineScientific Activity: publications, chapters andcollaborations in books specializing in confer-ences oral presentations and research linesrelating to pain management.

Interventional therapeutic strategies forthe treatment of pain

The management of patients suffering fromchronic pain has proven to be a complexprocess. Interventional and surgical techniquesshould be considered when pharmacologicaltreatment supplemented with physical exercisefailed to provide adequate relief or induced un-acceptable side effects. There are a multitude of interventional tech-niques in the management of chronic pain, in-

cluding not only neural blockade but also mini-mally invasive surgical procedures such as pe-ripheral nerve blocks, trigger-point injections,epidural injections, facet joint injections, sym-pathetic blocks, neuro-ablation techniques, in-tradiscal thermal therapy, disc decompression,vertebral reinforcement techniques like kypho-plasty, morphine pump implantation, and spinalcord stimulation.The epidural administration of corticosteroids,either by the interlaminar or transforaminalroute, allows precise application of cortico-steroids to the vicinity of the irritated nerveroot, resulting in massive concentration of theagent at the site and its therapeutic effect forthe management of spinal pain has been in-vestigated. Radiofrequency (RF) techniques in the manage-ment of different chronic pain syndromes isbased on interference in the conduction of nociceptive stimuli. The electric field generatedaround the electrode has the potential of pro-ducing modification of neural structures andneuronal behavior, which may also change painperception. Pulsed radiofrequency (PRF) wasintroduced in clinical practice as a non- or min-imal neurodestructive modification of conven-tional RF heat lesions. Improvements in the understanding of Intra-thecal drug delivery (IDD) and the drive forhigher standards in implantation procedure,combined with advances in technology and useof novel drug combinations of drugs such asbaclofen and morphine or clonidine contributeto successful treatment outcomes with IDD. Spinal cord stimulation, also referred to asSCS, has been applied successfully in a numberof indications, but is most often used to treatpostoperative neuropathic back and leg pain,most commonly called failed back surgery syn-drome (FBSS), and complex regional pain syn-drome (CRPS); The efficacy of SCS in CRPSand FBSS/CLBP has resulted in the techniquebeing used in other pain states, such as dia-betic neuropathy, post-traumatic neuralgia andpostherpetic neuralgia. Current applications ofelectrical neuromodulation implies its use atperiferal nerves but also in field stimulation in-dications.With all these possibilities interventional painprocedures must be carefully selected and ap-plied for achieving the best care for our pa-tients and providing at the end intended qualityof life.

Jose De Andrés

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Giovanni Apolone, MD Head Lab. for the Translational & Outcome ResearchHead Center for the Evaluation & Research on PainDept. of OncologyIstituto di Ricerche Farmacologiche „Mario Negri“Via La Masa 19, 20156 Milan – Italy+ 39 02 39014-515www.marionegri.it

BackgroundMost patients with advanced or metastaticcancer experience pain and despite severalguidelines, inadequate treatment is well docu-mented and can involve up to 43% of cases. InItaly cancer pain management is a major prob-lem as opioid consumption rates are amongthe lowest in Europe.

MethodsData were obtained from a multi-center, open-label, prospective, non-randomized studylaunched in Italy in 2006 to evaluate the epi-demiology, pattern and quality of care in cancerpatients. Data were collected using a web-based standardized system that allowed thecollection of several patients and physicians re-ported information and outcomes, mostly re-lated to pain and pain effects. To assess anal-gesic care adequacy, we used a standardizedmeasure, the Pain Management Index (PMI)that compares the most potent analgesic pre-scribed for a patient with that patient’s re-ported level of worst pain together with a se-lected list of clinical indicators. Univariate andmultivariable methods were used to assessthe relationship between PMI and potential pre-dictors.

ResultsOne hundred and ten centers recruited 1,801valid cases. Patients had severe pain (meanworst pain at baseline= 6.8), half had bonemetastases, episodes of breakthrough painand were still on active anti-cancer treatment,59% were recruited by oncologic centers, andmost were not aware of their prognosis. Sixty-one per cent of cases were receiving a WHO-level III opioid. In the whole sample 25.1% wereclassified as potentially inadequately treated,with large variations (from 9.8 to 55.3%) ac-cording to variables describing patients, cen-tres and pattern of care. After adjustment witha multivariable logistic regression model, typeof recruiting centers, receiving adjuvant ther-apy or not and type of patient recruited (newversus already on follow-up) had a significantassociation with inadequate treatment (oddsratio >1.2 and p-value <0.05). Non-compliancewith the pre-defined set of clinical indicatorswas in general high, ranging from 41 to 76%.

ConclusionAthough there are some intrinsic limitationsof the PMI as a measure of adequacy of analgesic care, findings suggest that recourseto WHO third step drugs is still delayed in apercentage of patients with cancer pain andthat this delay is probably related to severalfactors affecting the practice at participatingcenters.

Referencesvan den Beuken-van Everdingen MH, de Rijke JM,Kessels AG, et al. Prevalence of pain in patients withcancer: a systematic review of the past 40 years.Ann Oncol 2007; 18: 1437-1449

Maltoni M. Opioids, pain, and fear. Ann Oncol 2008;19: 5-7.

Cleeland CS, Gonin R, Hatfiled AK, Edmonson JH, etal. Pain and its treatments in outpatients withmetastatic cancer. NEJM 1994, 330: 592-596

Apolone G, Bertetto O, Caraceni A, Corli O, et al. Painin cancer. An outcome research project to evaluatethe epidemiology, the quality and the effects of paintreatment in cancer patients. Health Qo Life Out-comes 2006; 14;4(1):88

Deandrea S, Montanari M, Moja L, Apolone G. Preva-lence of undertreatment in cancer pain. A review ofpublished literature. Ann Oncol 2008; 19: 1985-1991

Apolone G, Corli O, Caraceni A, Negri E, et al. Patternand quality of care of cancer pain management. Re-sults from the Cancer Pain Outcome Research StudyGroup. Br J Cancer 2009 100 : 1566-1574

Giovanni Apolone

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Prof. Bernard Avouac MDDate of Birth : 1st may 1946

Bernard Avouac is a rheumatologist and asso-ciate Professor at the Liège University.

He is the former President of the TransparencyCommission of French Drug Agency which ad-vises the Ministry of Health and Social Affairson drug listing and pricing.He is currently a member of the Medical De-vice Reimbursement Commission (CNEDiMTS)in the HAS acting as an independent consult-ant.The main topics of his scientific research areclinical rheumatology, clinical Pharmacologyand pharmaco-economics.Dr. Avouac is the author of 340 congress pub-lications and communications.

Bernard Avouac

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Mary G Baker, MBE President, European Federation of NeurologicalAssociations

Mary Baker, MBE, is Patron and ImmediatePast President of the European Parkinson’sDisease Association (EPDA), a position she waselected to in 1992 when the EPDA was firstformed. Mary retired as Chief Executive of theParkinson’s Disease Society of the United King-dom in 2001 where she had worked for 18years.Mary is also President of the European Federation of Neurological Associations, VicePresident of the European Brain Council, Con-sultant to the World Health Organisation(WHO) and Chair of the Working Group onParkinson’s Disease formed by the WHO inMay 1997.

In 2008 the Council of Europe re-appointedMary for a second term as one of the patientrepresentatives to serve on the ManagementBoard of the EMEA, and in the same year shewas appointed to the IMI JU Scientific Com-mittee. In 2007 Mary was appointed to theCouncil of the ABPI and she is also a Memberof the ABPI Code of Practice. Other appoint-ments include Director at Large for the WorldStroke Association, former patient editor ofthe BMJ (now Chair of the BMJ Patient Advi-sory Group).

In 2009 Mary received the British Neuro-science Association Award for OutstandingContribution to British Neuroscience and forPublic Service and in 2003 an Honorary Doc-torate from the University of Surrey was con-ferred upon her in recognition of work withinthe world of Parkinson’s disease.

Mary Baker

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Sergi BlancafortTraining Manager at the University of Patients.Josep Laporte Foundation Autonomous Uni-versity of Barcelona, [email protected]

Degree in Biology at the University of Barcelona(1997). He is currently finishing his doctoralthesis in Sociology at the Autonomous Univer-sity of Barcelona. He has also completed post-graduate courses in non-profit organizationmanagement and training management.

He worked for seven years in clinical research(1997-2004). Since 2004 he has been thetraining manager at the Josep Laporte Foun-dation at the Autonomous University ofBarcelona. Between 2004 and 2007 he wasthe director of the Spanish Patients’ Forum.

He has been involved in several national andinternational projects related with public healthand clinical practice guidelines. He has pub-lished several articles and given several pre-sentations on different topics related with pa-tients’ organizations advocacy and trainingprograms in self-management. He has com-pleted the certification as Master Trainer ofthe Chronic Disease Self-Management Pro-gram at Stanford University (US).

Benefits of self-management programsHealth systems are facing deep social changes,such as the rise of a new model of patient anda transition of the patient-health professionalrelationship towards a new deliberative model.Health administrations and institutions are pro-moting the joint responsibility of patients andusers in self care, as well as an adequate useof health services and resources. The lack of health literacy is a common fact indeveloped countries, and it makes it difficult

for patients and users to get involved in healthdecisions. However, there are few studies thathave quantified and measured the prevalenceand costs of low health literacy, particularly inEurope, as well as the effect of low literacy onthe creation of inequalities in access to healthcare, particularly within vulnerable populationgroups such as the elderly, the disabled, low-income people, and those who are at risk ofsocial exclusion. Self-management programs have shown ben-efits related to chronic patients’ health anddaily life (managing symptoms of disease, ac-quisition of healthy life-styles, quality of life im-provement, communication with health profes-sionals), as well as benefits related with healthservices and resources (better adherence totreatments, less visits to primary care and hos-pitals, shorter stays in hospitals).The University of Patients (UP) is an academicproject promoted by Josep Laporte Foundationand the University Autonomous of Barcelona(UAB) in order to carry out training and re-search activities, and provide access to high-quality health information to patients and users.Training programs of the UP are aimed at pro-moting responsiveness and self-care of chronicdiseases, at achieving the necessary skills totalk and interact with health professionals, andat helping patients, relatives and carers to navigate through the health system.Patients and users’ health, welfare and qualityof life depend on healthcare, but also on theirknowledge and skills related to the self-man-agement of disease. Accordingly, people af-fected with chronic diseases are mainly re-sponsible for the management of their health,and trained patients can help other patientsto manage their chronic disease.

Health literacy and training programs in self-management of chronic diseases can becomean essential part of the social capital of a pop-ulation, can help reduce health inequalities andcan be one of the most important contributionsto the modernisation of health systems.

Sergi Blancafort

30

Meindert Boysen MScHPPFProgramme Director Technology Appraisals National Institute for Health and Clinical Excel-lence (NICE)

Meindert trained as a pharmacist in theNetherlands and joined NICE in 2004 as ahealth technology analyst in London. In 2006he accepted the post of Associate Directorwith the responsibility of setting up the newSingle Technology Appraisals programme forNICE in Manchester. Meindert previouslyworked as a hospital pharmacist and in rolesin health outcomes and sales in the pharma-ceutical industry. He completed an MSc inHealth Policy Planning and Financing at the Lon-don School of Hygiene and Tropical Medicineand the London School of Economics & PoliticalSciences and worked briefly for the King´sFund before starting at NICE.

Meindert Boysen

31

MARIJANA BRAŠ, PhD, MDPsychiatristDepartment for Psychological Medicine, UniversityHospital Centre Zagreb, School of Medicine Uni-versity of Zagreb

Marijana Braš was born in Osijek in Croatia on1971. She graduated at the School of Medicine inUniversity of Zagreb in 1995 as the best studentof the academic year. During study she receivedseveral different scholarships and participated indifferent scientific projects. Currently she is em-ployed as psychiatrist at the Department for Psy-chological Medicine at University Hospital CentreZagreb and as member of faculty at the Schoolof Medicine University of Zagreb. She finishedpostgraduate study of biomedicine at the Facultyof Natural Sciences in Zagreb and obtained MScdegree on 2005 as well as PhD degree on 2007.She finished postgraduate study on psychotherapyat the School of Medicine University of Zagreb on2009 and obtain master degree (psychotherapy)with the master thesis: „Posttraumatic stressdisorder and chronic pain“. In 2007 she finishedclinical subspecialty of psychotherapy. Her primaryareas of interests are chronic pain, psycho-oncology and palliative medicine. She is memberof the board of the Croatian Pain Society andpresident of the Croatian Society for PalliativeMedicine. She is co-chairman of the Task Forceon Pain Management of the World Federation ofthe Societies of Biological Psychiatry as well asmember of the Mentor-Mentee programme ofthe Collegium Internationale of the Neuro-psy-cho-pharmaco-therapy (CINP) under the mentor-ship of Prof. Lukasz Konopka from Chicago. Shewas NGO representative at the Department ofPublic Information of the United Nations (1993-1995). She is member of several national and in-ternational organizations (EFIC, IASP, AmericanPain Society etc.), with active participations atmany national and international meetings as well

as editor of several books and author of manyscientific papers and chapters in teaching books(also editor of teaching book about neuropathicpain). She is winner of the EGG (EFIC GrünenthalGrant) 2008 with the project: „The associationsof COMT polymorphisms with chronic low backpain in combat related PTSD“. Marijana is marriedand mother of two daughters.

Marijana Braš

32

Ailsa BrownPrincipal Health Economist Scottish MedicinesConsortium, Glasgow, Scotland.

Issues in the health technology assessmentof treatments for pain

The Scottish Medicines Consortium (SMC) pro-vides the health service in Scotland with adviceon the clinical and cost-effectiveness of all newmedicines with the aim of improving theprocess for the managed introduction of newtechnologies. The focus of this presentationwill be to give an overview of the work of theSMC, how economic models are used withinits process and some of the main issues thatarise with these health technology assess-ments. Discussion will be given on the trendsseen in the evaluation of the treatments forpain that have been submitted to SMC, along-side consideration of particular concerns thatarise in the health economic evaluation of suchtreatments.

Ailsa Brown

33

Dr. Ana Casas MD, PhDHead Area Medical Oncology University HospitalVirgen del Rocío Sevilla. Spain

PAIN IN ONCOLOGYPain is a frequent symptom in cancer patients.It may be due to the illness itself or totreatment. For many patients, pain is the mostfeared consequence of cancer. Unrelieved pain causes unnecessary suffering that can become psychologically devastating.Nevertheless frequently cancer patients do notexpress their pain adequately for fear that theirdoctor's attention will be drawn to thesymptom instead of focusing on the treatmentof the illness itself. It is very important forpatients to know that healthcare professionalsare ready to help them in all aspects, bothphysical and spiritual, providing comprehensivecare for their condition that is a globaltreatment approach to the disease.

While pain ranges between 30-90% of cancerpatients, thanks to the treatment currentlyavailable, cancer pain can be controlled in 95%of cases. Nowadays there is a wide range oftreatments and techniques available for thecontrol of cancer pain. They ensure thatsomething more can always be done to controlcancer pain, as intense as it may be. However,many people are frightened of taking opioidsfor fear of becoming "addicts". It is necessaryto convince them of the importance of usingthe appropriate drug when pain appears and

not when the situation has become completelyunbearable, overcoming the fear that the drugwill not take effect in future due to prolongeduse.

Despite the available treatment, there are still barriers that cause cancer pain to beunderestimated and undertreated. There arenumerous obstacles that have to be eliminatedin order to treat pain as adequately as possibleof which the following are the most important: Professional knowledge: improving theknowledge of healthcare professionals and torecognize the importance of the appropriatetreatment of all the symptoms that accompanycancer. Professionals must have access to permanent updates regarding bothpharmacological knowledge and analgesicmanagement skills.Lack of communication by patients: the fear ofthe patient to communicate pain intensity dueto the belief that this may distract the doctor'sattention and that the presence of pain means approaching death can difficult thecommunication of pain.Fear of becoming an addict. It is necessary tostress that there is no risk of addiction ifopioids are used correctly for pain relief. Fear of side effects. Some patients argue theywill lose control, fall asleep, be "drugged up" andbe unable to communicate socially or becomedependent on the medication.

Ana Casas

34

Roberto Casale, MDEFIC Councillor ItalySIMFER-SIG Chronic Pain, Co-ordinatorFoundation "Salvatore Maugeri"IRCCS Scientific Institute of Montescano Dept.of Clinical Neurophysiology Pain RehabilitationUnit

• Degree in Medicine and Surgery from theUniversity of Pavia in 1975.

• Specialization in Neurology in 1979 and inAnesthesiology and Pain Relief in 1987 atthe University of Pavia.

• Lecturer on Pain and Rehabilitation at theUniversities of Pavia, Siena and , Florence.

• Director of the Department of Clinical Neu-rophysiology & Pain Rehabilitation Unit, atthe Rehabilitation Institute of Montescano,"S. Maugeri” Foundation - IRCCS (Researchand Care Institute),Pavia, Italy.

• 2000-2004 AISD (Italian Association forthe Study of Pain) Councillor and Secretary

• From 2005 until present EFIC (EuropeanFederation of IASP Chapters) Councillor

• From 2004 up to the present Co-ordinatorof the SiG “Pain and Rehabilitation” of SIM-FER (Italian Society of Physical Medicine &Rehabilitation)

• Scientific interests: pain medicine : physio-pathology of pain and pain therapy; fi-bromyalgia; botulin toxin; neuropathic pain(CRPS); microneurography. Rehabilitationmedicine: rehabilitation of patients affectedby chronic pain and associated motor dis-ability (phantom limb pain); localized musclefatigue; rare diseases (scleroderma). Re-habilitation of central as well as peripheralnervous system lesions.

Chronic pain has a profound physical, socialand psychological impact, interfering with theperception of well-being and with daily life ac-tivities sometimes causing high levels of dis-ability . For these reasons in the last decadeseveral review articles in the rehabilitation fieldhave dealt with the presence of chronic pain inthe context of major neuro-rehabilitativepathologies such as stroke, head injuries,spinal cord lesions, multiple sclerosis, Parkin-son’s disease and other socially relevantpathologies such as low back and myofascialsyndromes.Recently an Italian survey found that 26% ofthe Italian population suffers from chronic painand that, overall, about 49% of Italian womencomplain of chronic pain with the percentageincreasing in those decades of life in which theneed for some rehabilitation intervention ismore likely. Interestingly, 69% of the peoplewho responded to an European based surveyreported having used at least one physical andrehabilitative treatment for their pain, includingmassage, TENS, heat and cold, acupunctureand exercise. However, although these datasuggest widespread recourse to physical andrehabilitation strategies to control pain and ahigh incidence of pain in people with pathologiesrequiring rehabilitation, as far as we are awarethere are no data about the incidence of painin a general rehabilitation setting. Here we are presenting the results of an Italiancross-sectional observational study on the in-cidence of pain in rehabilitation to raise theawareness that also in a rehabilitation settingthe presence of painful conditions representan unacceptable social burden.

Roberto Casale

35

Prof. José M. Castro-Lopes MD, PhDFull professor at the Faculty of Medicine of theUniversity of Porto, PortugalPresident of the National Observatory for Pain

Prevalence and socio-economic impact ofchronic pain in Portugal Azevedo L.F.*, Mendonça L.**, Dias C**,Costa-Pereira A*. and Castro-Lopes J.M.****Department of Biostatistics and Medical In-formatics and Center for Research in HealthTechnologies and Information Systems - CIN-TESIS; ** Department of Biostatistics andMedical Informatics; *** Institute of Histologyand Embryology of the Faculty of Medicine ofthe University of Porto and IBMC

Chronic pain has been proposed as a diseasein its own right and a major public health prob-lem, with socio-economic consequences com-parable to cardiovascular diseases or cancer.In order to design policies aiming at reducingthe burden of chronic pain, it is essential toknow its prevalence, management and socio-economic impact. Since no data were availableregarding the situation in Portugal, an epidemi-ological study was undertaken using themethod of Computer Assisted Telephone Inter-view - CATI. Telephone numbers were selectedby Mitofsky-Waksberg two stage random digitdialling sampling method, defining a randomsample of participants nationwide, resulting ina sample of 5,094 validated interviews of indi-viduals � 18 years old. Chronic pain prevalence, as defined by painpresent for at least 6 months, several timesper month and present during the last month,was estimated to be 29.6% (28.2 - 30.9, 95%CI). If a pain intensity criterion was used (mod-erate or severe; �5 on a 0-10 numeric ratingscale - NRS) the prevalence estimate was14.3% (13.3 - 15.4, 95% CI). As expected, theprevalence was higher in females and in-creased with age, with a peak prevalence of

moderate or severe chronic pain in 38.5% fe-males belonging to the age group of 70-74years (31.4 - 46.1, 95% CI). A more in-depth analysis was performed inthose respondents reporting pain for at least6 months and present during the last month,corresponding to 35.9% of our sample(n=2,210). Median pain duration was 10 years(5 - 20y, P25 - P75) and median average painintensity was 5 on a 0-10 NRS (4 - 6, P25 -P75). The main location of pain was the lowerback, followed by the lower limbs and neck. Osteoarthritis was the main cause of pain(42%) followed by intervertebral disk disorders(21%) and osteoporosis (15%). Pain manage-ment was carried out by family physicians ofthe public sector in most cases (61%), with amean of 4.5 visits/patient/year (VPY). A spe-cialist (secondary care) was consulted by 22%of the patients (4.3 VPY), only 1% consulted apain specialist (4.8 VPY). A large majority ofthe respondents (85%) were being treated fortheir pain, but one in five patients reported tobe dissatisfied or very dissatisfied with theirpain management, attributing it to lack of effi-cacy of the treatment or holding their physicianresponsible for it. Non-steroidal anti-inflamma-tory drugs were used by approximately 41%of the respondents, 26% used analgesics andantipyretics and only 2% took opioids. Approxi-mately 27% reported that they felt pain fre-quently or all the time while taking the pre-scribed drugs.In a third phase of the study, 300 patients wereinterviewed to evaluate the socio-economic im-pact of their chronic pain. Of these, 45% re-ported that pain interfered with their work, 9%had lost their job and 18% had early retirementdirectly due to their pain condition. On average,each patient had 14 days/year of sick leave.Taking into account the active population ofPortugal, its average salary and the welfarecosts associated with sick leave, an annual costof approximately � 250 million was estimated.Moreover, it was estimated that each patientspent on average approximately � 70/monthon direct and indirect costs associated withtheir pain, representing up to 35% of their fam-ily budget.In conclusion, chronic pain affects a sizeableproportion of the Portuguese adult populationand its management is far from being optimal.The high costs associated with chronic paincould be substantially reduced by investing hu-man and financial resources to increase its adequate management.

Jose M. Castro Lopes

36

Dr. Beverly Collett M.B.B.S., F.R.C.A.,F.F.P.M.R.C.A

Dr. Beverly Collett is a Consultant in Pain Med-icine at University Hospitals of Leicester NHSTrust.

She is Treasurer and Council member of theInternational Association for the Study of Pain(IASP), and was the facilitator for IASP’s GlobalYear against Pain for 2007/8 ‘Pain in Women’.She is Chair of the SIG ‘Pain of Urogenital Origin’(PUGO).

She is a Past-President of the British Pain So-ciety and of the International Pelvic Pain Societyand previously Honorary Secretary of the Eu-ropean Federation of IASP Chapters. She wasa member of the Founding Board of the Facultyof Pain Medicine of the Royal College of Anaes-thetists. She is Chair of the Chronic Pain PolicyCoalition (CPPC) – a group facilitating patients,parliamentarians and health care professionalsto improve pain management in the UK.

Medical professionals, patients and parlia-mentarians working together to improve themanagement of chronic pain.

In June 2006, the Chronic Pain Policy Coalition(CPPC) was launched to improve the lives ofpeople who live with chronic pain by developingand sharing ideas for more effective prevention,treatment and management of persistent painin the UK. It is an umbrella coalition of parlia-mentarians, health professionals and patientsworking together towards solutions for themanagement of chronic pain.The Chronic Pain Policy Coalition has produceda Five Point Pain Manifesto focusing on Educa-tion, Early Access, Empowerment, Collaborationand Measurement. We urge people to supportthe campaign to have pain recognised as theFifth Vital Sign in all health care locations. The Chief Medical Officers (CMO) Report in2008 highlighted the problem of persistentpain. The CPPC has since been working withthe Department of Health, the CMOs Officeand professional and patient organisations toensure implementation of the recommenda-tions. An All-Party Parliamentary Group for Chronicpain has now been formed and mutual closeworking has raised the profile of persistentpain as a public health issue.

Beverly Collett

37

Günter Danner M.A. PhD.Born 1955German and British national.University studies of history, economics and in-ternational relations in the U.K., Germany, theUS and South Africa.

Since 1982 working for the TechnikerKrankenkasse in Hamburg as a press spokes-person and later as an analyst of political andsocio-economic affairs in Germany and abroad.Today working as the personal advisor to theCEO and the Board of Management of one ofthe largest German health funds with approx.8 million insured people and 10 000 employeeson socio-economic, political and internationalaffairs.

Since 1993, in addition to the above-mentionedworking for the permanent Liaison Bureau ofGerman Social Security institutions in Brusselssince 1997 as the Deputy Director of this in-stitution.

Since 1992 as an international expert on healthcare systems, their administration, perform-ance and guiding political background frequentassignments on Commission projects in Cen-tral and East-European Countries (CEEC) undergoing social and economic transition aswell as Russia and China. Numerous publica-tions on issues dealing with international com-parison of social protection in particular healthcare. Author of the book “Die EuropäischeUnion am Scheideweg Wohlstandsprojekt, Wet-tlaufgesellschaft oder Wolkenkuckucksheim”,Meusch Verlag , Hamburg 2004. Frequent in-vitations as a speaker at national and interna-tional conferences on health and EU-relatedmatters. Regular academic teaching commit-ments e.g. in France, Germany, Sweden andthe US.Married, one child, 11 modern languages.

Günter Danner

38

Dr. Isabel de la MataPrincipal Advisor with special interest in Public HealthEuropean Commission

DG SANCOJean Monnet BuildingL-2920 LuxembourgTel.: +352-4301-31454Fax: + 352-4301-34511e-mail: [email protected]

Isabel de la Mata was born in Bilbao (Spain).She graduated in Medicine at the University ofBasque Country in 1983 and holds post-grad-uate degrees from the University of Leuvenand Paris VI. She is a specialist in PreventiveMedicine and Public Health.

She worked at the Ministry of Health of Spainand at the Regional Departments of Health inthe Basque Country and in Madrid. She hasexperience working with International Organi-sations, such as the WHO, Pan AmericanHealth Organisation and Inter-American Development Bank.

From 2004 until February 2008 she workedat the Permanent Representation of Spain tothe EU.

Since 1 March 2008 she has been workingas Principal Adviser for Public Health at Direc-torate SANCO – Health & Consumers.

Isabel de la Mata

39

Prof. Jan Dobrogowski MDPresident of Polish Pain SocietyHead of Department of Pain Research andTherapyChair of Anesthesiology and Intensive TherapyJagiellonian University, Collegium MedicumSniadeckich 1031-531 KrakowPolandPhone/Fax: +48 12 421 08 85E-mail address: [email protected]

PREVALENCE OF NEUROPATHIC PAIN IN POLANDNeuropathic pain has been recently defined aspain arising as a direct consequence of a lesionor disease affecting the somatosensory sys-tem. It is often cited that 1.5% of the generalpopulation is affected by neuropathic pain; how-ever a UK study found that the prevalence wasabout 8.2% (17% of patient with chronic pain).That difference indicates the difficulty of diag-nosing and estimating precisely the prevalenceand incidence of neuropathic pain. The aim ofthe study was to determine the occurrence ofselected kinds of neuropathic pain in the gen-eral population in Poland, in which the patho-physiology of the somatosensory nervous sys-tem lesion was obvious.The Polish Pain Society asked the Polish Na-tional Health Fund to provide data concerningthe prognosis of neuropathic pain syndromesamong out-patients on the basis of ICD-10 in2008-2009.Data provided by NHF revealed that in 2008-2009 different neuropathic pain syndromeswere diagnosed and treated in 111 041 pa-tients (0.3% of the general Polish populationand 1.46% of chronic pain patients). The mostcommon neuropathic pain syndromes diag-nosed by primary care physicians and otherspecialists were:

• mononeuropathy of upper extremity (G56) - 63 433 patients (57% of all neuropathicpain patients),

• mononeuropathy of lower extremity (G57) - 22 225 patients (20%)

• trigeminal neuralgia (G50) - 18 092 patients (16.3%)

• painful polineuropathy (G63) - 7 291 patients (6.6%).

The occurrence of neuropathic pain in the Polish population is slightly lower than expected;however in this estimation not all types of neu-ropathic pain were taken into consideration.

Jan Dobrogowski

40

Prof. Isabelle Durand Zaleski MDHead of Public Health Henri Mondor, Créteil, France

Education: MD, University of Paris 1985Master of Public Policy, Institut d’Etudes Poli-tiques de Paris 1985Master of Public Health, Health Policy and Man-agement, Harvard University, Boston 1986Ph D in Economics, University of Paris IX 1991

Current position:Professor of Medicine, University of Paris, chief, Public Health, Henri Mondor hospital,Paris, France

Past position:Director of evaluation and health care coverageat the French National Health Authority

As the chief of the department of public health,Prof. Durand-Zaleski is in charge of developingsupport methods for support clinical research(mostly hospital-based research), for the as-sessment of new technologies, including eco-nomic assessment.She teaches health economics and health tech-nology assessment at the University of Paris12. Research interests include health policy andpolitical economy (the translation of researchfindings into policies and assessment of inno-vation in medicine.

Address for correspondence : Isabelle Durand-Zaleski, Santé Publique, Hôpital Henri Mondor,51 avenue du Maréchal de Lattre deTassigny,94010 Créteil, Francetel : + 33 1 49 81 36 74fax : + 33 1 49 81 36 97email : [email protected]

Isabelle Durand Zaleski

41

Dr. Benjamin EllisClinical Advisor to the Chief Medical OfficerDepartment of HealthLondon, United Kingdom

Currently seconded from the NHS as a ClinicalAdvisor to the Chief Medical Officer and to theWHO Patient Safety Programme where he isProgramme Manager for the WHO PatientSafety Curriculum Guide.

Benjamin is a Specialist Registrar in Rheuma-tology and General Medicine. He holds an MScin Rheumatology from King's College Londonand will soon enter the second year of a Masterof Public Health degree from Johns HopkinsUniversity.

Benjamin plans to continue his clinical trainingin autumn of 2010, working flexibly to enablehim to continue his work at the World HealthOrganization along with pursuing his interestsin long term conditions management and serv-ices for people with chronic pain.

Benjamin Ellis

42

Dr. med. Gottfried EndelHauptverband der Österreichischen Sozialversicherungsträger

MEDICAL DEGREE:1975 – 1983 Vienna University Medical School13.10.1983 Conferral of doctorate in medicine01.01.1988 General practitioner

PROFESSIONAL CAREER:01.01.1985 – 31.12.1987 Intern / resident01.01.1988 Entrance to the Austrian Social Insurance Authority for Business

(SVA), central office, department for Prior Authorization and Physicians’ Control

since 02.10.1989 General practice in 3400 Klosterneuburg

24.03.1993 Appointment as emergency doctor01.10.1993 Appointment as permanent deputy head physician of the

Department for Prior Authorization and Physicians’ Control01.12.2003 Head physician of the Department for Prior Authorization

and Physicians’ Control in the Austrian Social Insurance Authority for Business (SVA)

01.05.2004 Head of the Department of Evidence Based Health Care in the Main Association of Austrian Social Insurance Institutions

MAIN COMPETENCES:• Evidence Based Medicine and Health Technology Assessment• Health economy, Medicinal product economy• Differentiated service-oriented fees regulated

comprehensively (LKF)• Federal long time care allowance• Austrian pension system• Medical opinions• Project management, quality management, business

process engineering• Data protection, data security• Digital signature, e-health and e-government

Information: www.hauptverband.at/EBM_HTA

Gottfried Endel

43

Dr. Cornelius ErbeMember of the Extended Board - Head of Product Management D A K - Unternehmen Leben

Dr. Cornelius Erbe is currently holding a positionas senior vice president and member of theextended Board of Deutsche Angestellten-Krankenkasse (DAK); Hamburg/Germany. DAKis the third largest German statutory healthinsurance organization with 4.8 million mem-bers and 6.3 million insured persons. Dr. Erbeis head of Product Management and is respon-sible for developing and contracting all medicaland paramedical services for DAK’s members.

Previously, Dr. Erbe held positions as a partnerat Roland Berger Strategy Consultants, and asa product manager for diabetes pharmaceuti-cals at Boehringer Mannheim, Mannheim/Ger-many. Dr. Erbe studied medicine at Albert-Lud-wigs-University, Freiburg/Germany.

Analyses of types and costs of pain - basedon 6 million insured persons

In the past the treatment of patients withchronic pain has rarely been studied in largepopulations. Thus little is known about the fre-quency of pain associated with various under-lying conditions, the cost incurred when caringfor patients with chronic pain and the effec-tiveness of various interventions.

Past analyses focused on selected patientgroups and the care of patients with chronicpain from the perspective of a third-party payeroffering comprehensive health care coveragehas not been studied. One main reason for thislack of studies is the fact that the ICD-10 (In-

ternational Statistical Classification of Diseasesand Related Health Problems 10th Revision)does not provide the codes necessary to clas-sify pain. Thus patients with chronic pain, atleast until 2009, could not be identified via ICD-10 diagnostic codes.

In a cooperative health services research proj-ect IGES Institut (Berlin), Grünenthal GmbH(Aachen), and DAK – Unternehmen Leben(Hamburg) developed a novel algorithm to iden-tify patients using health insurance claims data.DAK – Unternehmen Leben is the third largeststatutory health insurance in Germany coveringabout 6.2 million individuals.

Within this population the study identified pa-tients with pain, classified various types of painand analysed treatment costs from the per-spective of a third-party payer.

The algorithm used to identify patients and theapproach to classify different types of pain willbe presented. Two methods of allocating treat-ment costs will be discussed highlighting theirrespective strengths and limitations. Resultswill be shown for the subgroup of patients withback pain with respect to prescribed drugs aswell as the main cost drivers.

Attempts will be made to interpret differentlevels of costs observed at different stages inthe course of the disease. These results offernew starting points for the prevention ofchronicity and consequently also for the reduc-tion of costs.

This investigation constitutes a milestone inthe study of pain under the conditions of routinecare and serves as a new empirical foundationfor discussions on the proper identification ofpatients eligible for managed care programsaimed at increasing treatment efficiency andreducing costs through adaequate, stage-adjusted care.

Cornelius Erbe

44

Prof. Serdar Erdine MD,FIPPPresident of World Institute of Pain

Chronic Pain; a disease without a name

Chronic unrelieved pain is a major unsolvedhealthcare problem world-wide. It is universal,has enormous financial costs and is a tremen-dous burden in terms of quality of life for sufferers and their families and immediate so-ciety. Unfortunately due to recent develop-ments and improvements in Pain Medicine,there is a difference between what can bedone, and what is done for pain. Pain relief asa human right may be misinterpreted by thepublic and by health professionals. Pain man-agement is not a priority with governmentsand health providers, thus the resources areinadequate for treatments including analgesicsand dedicated pain management teams. Phar-maceutical companies have limited interest inproducing low cost medication for the treat-ment of pain.In September 2008, the World Health Organ-ization (WHO) estimated that approximately80 percent of the world population has no, orinsufficient, access to treatment for moderateto severe pain and that every year tens of mil-lions of people around the world, includingaround four million cancer patients and 0.8million HIV/AIDS patients at the end of theirlives suffer from such pain without treatment.“Please, do not make us suffer any more…”(http://www.hrw.org./)A large scale of survey conducted in 46,394respondents over 18 years of age showedthat chronic pain of moderate to severe inten-sity occurs in 19% of adult Europeans, seriouslyaffecting the quality of their social and workinglives. 19% had lost their job and 13% hadchanged jobs because of their pain. 60% visitedtheir doctor about their pain 2-9 times in the

last six months and only 2% were currentlytreated by a pain management specialist. One-third of the chronic pain sufferers were cur-rently not being treated. Forty percent had in-adequate management of their pain (3), Inanother study in Europe (4).Thus we çan easily say that chronic pain is adisease still without a name.

1. Erdine S. Chronic pain a disease without aname. Med Pregl. 2007; Sep-Oct. 60(9-10): 417-9.

2. Access to Pain Treatment as a HumanRight; Humar Rights Watch, March 2008.http://www.hrw.org./en/reports/2009/03/02/ please - do - not- make - us - suffer - any - more

3. Breivik H, Collett B, Ventafridda V, Cohen R,Gallacher D. Survey of chronic pain in Eu-rope: prevalence, impact on daily life, andtreatment. Eur J Pain. 2006; May. 10(4):287-333. Epub 2005 Aug 10.

4. Survey of Pain in Europe, Quantitative re-search among patients by age, gender andweak vs. strong opioid users,Mundipharma. 2005; March 9.

Serdar Erdine

45

Norman EvansConsultant in Pharmaceutical Public Health-World Health Organisation Collaborating Cen-tre Department of Primary and Social Care Im-perial College, London

Norman Evans was previously Chief Pharmacistat Wandsworth Teaching Primary Care Trust,London and before that Senior Lecturer inPharmacy at King's College. London. As ChiefPharmacist he was responsible for the policyand strategy for medicine use and diseasemanagement within the local health economyacross the primary and secondary care inter-face. He was the lead or actively involved inthe development of many clinical guidelines. Hehas long been concerned about the societalimpact of pain and helped to implement localpain management guidelines

Today he is a Consultant in PharmaceuticalPublic Health at the World Health OrganisationCollaborating Centre, Department of Primaryand Social Care, Imperial College, London.

Norman is also a member of the EditorialBoard of a new journal called "Managing Painin Practice".

Norman Evans

46

Francis Fagnani, PhD, M.B.A.,Director at CEMKA, a consulting group in healthEconomics, Epidemiology and Outcomes re-search located in Paris (France)

Francis Fagnani has dedicated most of thepast 25 years to the domain of public health,medico-economics and outcome research. Hejoined the French National Institute of Healthand Medical Research (INSERM) in 1968where he was Research Director.In the years 82-90, he was director of the IN-SERM unit (U. 240) « Risk assessment andprevention program evaluation ». He is cur-rently Director of CEMKA, which he created in1990. Since 1990, Dr FAGNANI has focusedhis activity on Pharmaco-Economics, Epidemi-ology and Outcome Research in a large varietyof therapeutic domains. During the period92/97, he acted as expert in the TransparencyCommission within the French MedicineAgency, in charge of pharmaceuticals assess-ment and reimbursement policy. As a memberof the French College of Health Economists, hewas actively involved in the writing of the FrenchGuidelines for Pharmaco-Economic studies. DrFAGNANI has been a member of numerous na-tional and international advisory groups andprofessional societies. At INSERM and CEMKA,he has conducted a wide range of studies onthe cost of illness and cost-effectiveness ofdrugs, medical devices and public health pro-grams in a variety of settings.

Francis Fagnani

47

Prof. Guido Fanelli MD

Head of the Chair of Anesthesia and ICU at the University ofParma, School of Medicine;

Head of the Postgraduate School (School of Specialization)of Anesthesia ICU and Pain at the University of Parma, Schoolof Medicine.

Chief of Pain and Palliative Care Commitee of Minister ofHealth, and Wellfare – Italian Government

Member of Advisory Committee for Ministry of Health– Ital-ian Government

Member of Health Supreme Committee – Italian Govern-ment

Referee and reviewer for Italian Minister of Health (AIFA)for Indipendent research

Date and Place of Birth18-12-1955 Olgiate M. (Lecco) Italy

Education1983 Degree in Medicine - University of Milan.

Postgraduate Training and Fellowship Appointments1986 Postgraduate Study in Anaesthesiology and ICU Uni-versity of Milan.

Main Previous Appointments1986 -1997 Staff Anesthesiologist ,Consultant in charge

at the Chair of Anesthesia and ICU, SanRaffaele Hospital, Milan.

1997 -2001 Coordinator and chief in charge of the Cen-tral (Head) Multidisciplinary Operating Unitand of the organization of:a. A.P.S. (Acute Pain Service)b. General pre-operational ambulatory

anesthesiac. Sedation Service Extra Operational Room

(SEO)

2002 Head of the Dept. of Anesthesia ICU and Pain Therapy University of Parma.

2003 Pass certificate as Full professor, Dept. of Anesthesia and ICU;Call to Professor Full, Dept. of Anesthesia and ICU, School of Medicine, University of Parma.

2004 Director of the Post Graduate School of Anesthesia and ICU, University of Parma.

2007 Referee and reviewer for Italian Minister of Health (AIFA) for Indipendent research

2008 Chief of Pain and Palliative Care Commission Minister of Health, Wellfare - Italian GovernmentMember of Advisory Committee for Ministry of Health– ItalianGovernment Member of Health Supreme Committee – Italian Government

Teaching Activities

1990 – 1995 Director of workshops on local-regional anes-thesia therapies and the post-operative pain control at PostGraduate School of Anesthesia and ICU in Milan, Bologna,Messina, Barcelona (Spain).

1999 Teaching local and regional anesthesia therapies andpost-operational pain control at the Texas University Schoolof Medicine, Houston, Texas, USA.

1988 – 2000 Lecturer at the post Graduate School of Or-thopaedics and Traumatology at the University of Milan; Tutorof the Ist Postgraduate School of Anesthesia and ICU;

2001 Lecturer at the Postgraduate School of Anesthesiaand ICU, Academy “Vita e Salute”, San Raffaele Hospital, Mi-lan.2002 Lecturer at several postgraduate schools (anesthesia,ICU, internal medicine, orthopedic surgery, etc.), Universityof Parma;

2002 – 2004 Chairman of the Scientific Committee forRegional Anaesthesia of the European Society of Anaesthe-siology (E.S.A).

2003 – today Visiting Professor in Regional Anesthesiaand Pain at the UPMC (Pittsburgh Medical Center)

Experiences in Clinical TrialsSince 1988 he has carried out 110 Clinical Trial in phase2b and 3b according to Good Clinical Practice

Member of the following scientific societies:Member of the national council of the European Society ofRegional Anesthesia (E.S.R.A). since 1991.Life-Member of the European Society of Regional Anesthesia(E.S.R.A).

Member of the American Society of Regional Anesthesia(A.S.R.A).

Member of the Permanent Commission of Italian Society ofAnesthesia Analgesia Reanimation and Intensive Care(S.I.A.AR.T.I) for relations with the foreign scientific societies.

Invited Speaker at over 100 national and international meet-ings.

He is author of more than 280 publications of which:• 274 with Impact Factor

(Mean Impact factor 2.24)• 16 Books or Chapter in Books

Research field of interest: Pain, regional anesthesia, thromboprophylaxis, anticoangu-lant, organizational issues in operative and ICU settings,haemodynamics in anesthesia

Guido Fanelli

48

Dr. Marcelo Rivano Fischer

EDUCATION AND EXAMENS

1992 Board licensed in psychology (Authorization from the National Swedish Board of Health and Welfare)

1988 University Degree, Philosophy Doctor in Psychology, Lund University, Lund

PROFESSIONAL APPOINTMENTS AND POSITIONS2002- Head of Department (Chairman), Department of Rehabilitation,

Skånes University Hospital, Sweden2000-2001 Program director and Chief of staff, Pain unit, Department of Rehabilitation,

Lund University Hospital, Lund1998-2000 Program director and Chief of staff, Pain Rehabilitation unit,

Department of Rehabilitation, Lund University Hospital, Lund1994-2000 Senior Psychologist, Department of Rehabilitation, Lund University Hospital, Lund1991- Psychologist, Department of Rehabilitation, Lund University Hospital, Lund

EXAMPLES OF OTHER POSITIONS AND ASSIGNMENTS2009- Co-tutor of PhD student in Rehabilitation Medicine, Lund University,

Faculty of Medicine2009- Member of the Southern Region Medical Counselling Board

on Muskuloskelettal diseases and Pain (Södra regionen Medicinska råd för Sjukdomar I Rörelseorganer och smärta), Sweden

2009- President, Swedish Pain Society, member of The International Association for the Study of Pain (IASP), Sweden

2008 Co-Organizer of Specialty national course in Methodology in Rehabilitation Medicine

2005-2009 Chairman, Pain Forum (National Association for Pain Professionals)2004- Surveyor (Medical Rehabilitation) for the CARF Commission for the

Accreditation of Rehabilitation Facilities (CARF international), USA2003- Reviewer, Journal of Rehabilitation Medicine (Sweden), Sweden2003- Guest teacher, Pain and Psychology, Physiotherapy School, Faculty of Medicine,

Lund University, Sweden2003- Guest teacher, Behavioural Medicine, Medical School, Faculty of Medicine,

Lund University, Sweden2002- Co-Organizer of Specialty national courses in pain and Pain Rehabilitation

(2002, 2004, 2009)2001-2008 One-day education for pain professional on psychological aspects of pain, Multidisciplinary

Pain Centrum, Gothenburg University (yearly)1998- Member of the Board for the National Register of Pain Rehabilitation, Sweden

Marcelo Rivano Fischer

49

Joana GabrieleDirector of Spanish Patients’ Forum

The impact of pain from the patient perspectivePain is a relevant and unsolved problem thataffects millions of people worldwide. Accordingto the International Association for the Studyof Pain (IASP), pain is a major global healthcareproblem, a disease in its own right. Numerousstudies have emphasized the devastating con-sequences derived from inadequately treatingpain for the sufferer and for an entire family inclinical, social and economic terms. Despitethis, little research has been done to explorethe holistic impact of chronic pain on patientsand relatives from a sociological and behav-ioural point of view. Not in vain, pain and moreespecially chronic pain is not only an individualproblematic but also a very complex paradigmthat shows the importance of knowing the di-mensions of the pain experiences and the be-haviour of patient resulting from health careand social system misconceptions, gaps andbarriers.

The main aim of this paper is to present thehigh cost of pain, directly and indirectly, fromthe human and social dimension, or expressedin other words, from a patient-centred pain ap-proach. The purpose is to try to demonstratethat pain and more particularly chronic pain isa determinant of health per se. In fact, througha narrative approach of pain from the moresignificant patients’ journey pain experiencespresent in the literature research, we showthat the impact of pain is not only a relevantdeterminant on the patient self-concept but acrucial determinant of health correlate of pa-tient behaviour. Because of this, the knowledgeand subsequent adaptation of health care andsocial system to patients’ attitudes, beliefs, per-ceptions and experiences are an excellent

source of expertise that should be consideredand applied in health, ethics, gender and policymaking agenda.

About of the Spanish Patients’ Forum “Thepatients’ voices in democracy”http://www.webpacientes.org/fep/

Spanish Patients Forum, member of the Euro-pean Patients’ Forum from 2006, set up in2004 in Barcelona with the aim of establishinga permanent forum of discussion for patients’organizations at European, national, regionaland local levels. At the present moment, theForum represents 685,276 members and1,040 organizations from diverse diseases(cancer, cardiovascular diseases, Alzheimerand dementia, diabetes, rare diseases… andconditions (pain). It has the task of becoming areference organization in the representationof the organizations at five main scenarios: so-cial, political, scientific, academic and industrial.One of the main objectives of the Spanish Pa-tient Forum is to promote a higher advocacyof patients’ rights in the following fields: pa-tients’ involvement in health priority setting; for-mal democratization of health care decisions;recognition of patients’ organizations as healthpolicy agents; improvement of the knowledgethat patients have on their basic health carerights; finally, quality assurance and measuringpatients’ basic health care rights.

Joana Gabriele

50

Dr. Livio GarattiniDirector of CESAV, Centre of Health Economics, Mario Negri Institute

Livio Garattini : obtained a degree in economicsin March 1983 c/o Bocconi University in Mi-lan.Educational activities: “King’s Fund College”, Lon-don: courses of health care management; “Cen-tre for Health Economics”, York: bibliographicanalysis of publications on NHS; “Ecole Na-tionale de la Santé Publique”, Rennes: coursesof health care management.Areas of interest: health economics and healthcare management.

At present: Director of CESAV (Centre of HealthEconomics A. e A. Valenti - M. Negri Institute);1981-1983: researcher c/o M. Negri Institute;1983-1984: clerk c/o Banca Commerciale Ital-iana in Milan; 1984- 1985: senior consultantc/o “Sogess srl” in Milan; 1985-1990: re-searcher c/o Bocconi University in Milan.Selected publications:1) Garattini L, Cornago D, Tediosi F (2001) “A

comparative analysis of domiciliary oxygentherapy in five European countries” HealthPolicy 58:133-149.

2) Garattini L, De Compadri P, Clemente R,Cornago D (2003) “Economic Evaluationsin Italy: a Review of the Literature” Interna-tional Journal of Technology Assessmentin Health Care 19(4): 685-697.

3) Beghi E, Garattini L, Ricci E, Cornago D,Parazzini F on behalf of the EPICOS Group(2004) “Direct Cost of Medical Manage-ment of Epilepsy among Adults in Italy: AProspective Cost-of-Illness Study (EPICOS)”Epilepsia 45(2): 171-178.

4) Garattini L, Barbui C, Clemente R, CornagoD, Parazzini F on behalf of the Study Group

SCORE (2004) “Direct Costs of Schizophre-nia and Related Disorders in Italian Com-munity Mental Health Services: A Multicen-ter, Prospective 1-Year Follow up Study”Schizophrenia Bulletin 30(2): 295-302.

5) Ricci E, Cortelazzo S, Krulichova I, GarattiniL (2005) “Direct medical costs of mycosisfungoides in specialized Italian hospital de-partments” Haematologica 90: 270-272.

6) Ghislandi S, Krulichova I, Garattini L (2005)“Pharmaceutical policy in Italy: towards astructural change?” Health Policy 72: 53-63.

7) Barbui C, Motterlini N, Garattini L (2006)“Health status, resource consumption, andcosts of dysthymia. A multi-center two-yearlongitudinal study” Journal of Affective Dis-orders 90: 181-186.

8) Garattini L, Ghislandi S (2006) “Off-patentdrugs in Italy- A short-sighted view?” TheEuropean Journal of Health Economics7(1): 79-83.

9) Cornago D, Li Bassi L, De Compadri P,Garattini L (2007) “Pharmacoeconomicstudies in Italy: a critical review of the liter-ature” The European Journal of Health Eco-nomics 8(2): 89-95.

10) Garattini L, Motterlini N, Cornago D (2008)“Prices and distribution margins of in-patent drugs in pharmacy: A comparisonin seven European countries” Health Policy85(3):305-313.

11) Garattini L, Casadei G (2008) “Health tech-nology assessment: for whom the belltolls?” The European Journal of Health Eco-nomics 9(4):311-312.

12) Gritti S, De Compadri P, Garattini L (2007)“L’informazione medico scientifica fra Statoe Regioni” Quaderni di Farmaco Economia4: 7-15

13) Casadei G, Gritti S, Garattini L (2009) “Lagestione dei vaccini nelle ASL lombarde:un’indagine in nove province” Quaderni diFarmaco Economia 8: 17-25.

14) De Compadri P, Koleva D, Mangia A, Mot-terlini N, Garattini L (2009) “Analisi costominimizzazione della terapia di durata 12 o24 settimane di peginterferone alfa-2b edi ribavirina nell’infezione da virus del-l’epatite C” Quaderni di Farmaco Economia10:7-16.

Livio Garattini

51

Antonio GaudiosoAntonio Gaudiosovice secretary generalCittadinanzattiva, Italy

WORK EXPERIENCECurrent position: since 2002 Deputy Secretaryof Cittadinanzattiva-Active citizenship networkand responsible for national and internationalrelations with the stakeholders of theorganisation, for instance the ItalianGovernment and Parliament, the EuropeanCommission, European Parliament.

Vice President of Active Citizenship Foundation.

He is regularly invited to take the floor asspeaker in national and internationalconferences and seminars on the theme ofcitizens’ rights, welfare systems and corporatesocial responsibility.

Concerning the health field, he takes part (andhe has also participated in the preliminaryworks of the Committee) in meetings/hearings with the National Drugs Committee(Commissione Unica del Farmaco /AIFA)where access to drugs related to chronicillnesses is discussed.

In 2002 he contributed to the drafting of theEuropean Charter of Patients’ Rightspromoted by Active Citizenship Network, theEuropean program of Cittadinanzattiva. He started his collaboration withCittadinanzattiva in 1996 taking up theresponsibility of launching the first PIT Salute:a free daily service offering information, adviceand assistance to all citizens in order tosafeguard their rights in the field of welfare andhealth, for both public and private facilities.Later, he became the director of this service

that, to this day, deals with thousands ofcitizens’ complaints and requests for advice. Aconsiderable number of these complaintsconcern access to drugs.

Following this experience, he started workingon several themes connected with theprotection of health rights. For instance, heengaged in the process of adoption of the firstLaw on Pain in 2000; he participated in theroundtable “Quality Alliance” triggered byCittadinanzattiva and involving pharmacistsand both hospitals and GPs in the discussionof the quality of health services; and finally, hetook part in several information campaignsrelated to the protection of rights, specificallythe right to innovation on health services.

Some of most important initiatives/campaignswere dedicated to:- the introduction of generic drugs;- access to pain relief drugs;- supporting the creation of the Coalition of

Associations for Patients Suffering ChronicDiseases;

- the promotion of the “Premio Alesini” - anannual award for best practices in health;

- the promotion of the right to informedconsent;

- the promotion of safety and risks’ pre-vention in the hospitals;

- civic audit in the health structures (programalready adopted by the Minister of Health inItaly).

Currently he is a member of several com-missions and working groups on health in Italyand Europe (for example the Oncology PatientAdvisory Board at Roche and Health AdvisoryBoard at EuropaBio).

Place and date of birth: Battipaglia (SA) - July7th, 1972 Citizenship: Italian

EDUCATIONGraduated in Political Science and InternationalRelations– University of Macerata Summer School on HTA at London School ofEconomics

Antonio Gaudioso

52

Prof. Pietro Giusti MDfull Professor of Pharmacology at the Universityof PaduaDirector of the Department of Pharmacology& Anesthesiology “E.Meneghetti”Largo Meneghetti, 2, 35131Padova, Italy

Cost of management of patients withchronic pain: an analysis of prescription andservices data in the Treviso Local HealthUnit (Italy)

Until recently, Italian legislation was veryrestrictive concerning the medical use ofopioids [Mercadante, 2002], making Italy oneof the lowest users of opioids in Europe. In aprevious survey of opioid prescriptions issuedfor cancer outpatients in one district of theVeneto Region between 1993-2000 [Salvatoet al., 2003], we found that the vast majorityof terminally ill outpatients received inadequateopioid prescriptions in terms of either dose ortherapy duration. These findings closelyreflected the general situation in Italy[International Narcotics Control Board. Reportfor 2000, New York. United Nations, 2001]. In2001, the Italian government eased the law onopioid prescription [Mercadante, 2002] andintroduced changes including: simplification ofprescription forms; an increase in the amountof opioids that can be prescribed at one time,allowing physicians to prescribe two differentopioids in the same prescription instead of onlyone; a reduction of sanctions for inadvertentprescription or dispensing errors. Althoughthere was an increase in opioid use in Italyfrom 16 defined daily doses (DDDs)/100,000inhabitants/day in 2000 to 45 in 2002,

morphine and buprenorphine consumptionremained unchanged. The increase wasentirely due to the introduction of transdermalfentanyl in the list of drugs reimbursed by theItalian National Health Care System [Chinellatoet al., 2003], and not to the change inlegislation. In the present study, we evaluatethe prescription patterns of opioid analgesicsin the local Health Unit of Treviso (VenetoRegion) in the period 2000-2009.

Pietro Giusti

53

Dr. Alberto Grua Grünenthal GmbH52099 Aachen, Germany

Can pain be helpful as a quality indicator forhealth care systems?

• The number of patients affected by pain isvery significant.

• The economic and social burden of chronicsevere pain is derived from inherent directcosts and indirect costs. The global cost ofpain is probably largely underestimated.

• Looking at the available data we find a veryheterogeneous situation across Europe inthe management of pain.

• This indicates for the health care systemsthat best practice in prevention and man-agement of pain are sparsely shared overEurope.

• Because of its high prevalence and impacton patients and society, pain should be rec-ognized as a significant health care qualityindicator.

• Improved knowledge on the societal impactof pain will help us to define measures to im-prove the clinical and economical burden ofpain.

• The definition of clear health care indicatorsmeasuring pain in the population will supportthe implementation of a best practice ap-proach to improve care.

Alberto Grua

54

Ewald Gspurning, MPH

Styrian Back Pain SurveyCurrently the discussions about rationing andrationalisation of solid financed services in thehealth care system are taking place in Austria,as well as in many other western industrialcountries. The increase of chronic diseases isa topic often at the top of the agenda and iscurrently a great expense factor in the healthservice. Chronic back pain is still a medical andhealth-political challenge because of the highoccurrence rates in the western industrial pop-ulation. Furthermore, chronic back pain in acontext of a political and ethical dimension ofpublic health raises questions about values inour society such as a fair distribution of limitedresources, the responsibility of the stakehold-ers and the basis of their information andknowledge, the impact of system changes onthe health-related quality of life and the cost-benefit ratio.The aim of the survey was the generation ofstatistical information about the epidemiology,the time course and the associated risk factorsof the „common disease“ back pain in Styria,which is one of nine states in Austria with apopulation of about 1.2 million.The “Styrian Back Pain Survey” is a regionalpopulation-based postal survey of 12,000 ran-domly chosen, age and gender-matched per-sons of the Styrian general population con-ducted from April to June 2008. The selectionof the surveyed people between the ages of19 and 79 years was carried out on the basisof documentation files of the social health in-surance of the state of Styria.The survey delivers a cross sectional snap shotof the prevalence of back pain as well as gen-der-related and age-related distribution of backpain in the Styrian population. In addition, ananalysis of possible factors, which influence theutilization of the health care system, is per-formed. On the one hand, the report deliversactual data about the correlation between LBPand demographic characteristics, individual

lifestyle, subjective locus of control, quality oflife and on the other hand findings about thelevel of satisfaction with the present back paintreatment.The results of the survey showed a high num-ber of one-year prevalence of back pain (male:61.4% - female 58.6%) among the Styrian pop-ulation. More than one in five adults in Styria(21.5%) suffered from chronic back pain lastyear. Statistics showed only slight gender-specific differences.The variables like age and education have astrong influence on the clinical picture andhealth care utilization. The percentage of indi-viduals with chronic pain in the group of the+60 year olds is six times higher than in thegroup of the under 30 year olds. There is alsoa big difference in the prevalence of chronicback pain between individuals with the lowesteducation (26.5%) and highest education(15%). Less than half of the patients (48.1%)with back pain consult a doctor and most ofthem a general practitioner. Approximately10% of patients with chronic back pain changedtheir physician more than three times duringthe last year as a result of ineffective pain treat-ment.In a nutshell many findings of the survey havebeen known for a long time. We see that indi-viduals of higher age, lower education, over-weight and a pronounced “external locus ofcontrol” have a stronger inclination to chroniccourse of pain. Moreover, the type and theterms of employment, the job characteristicsand the socio-economic and the psycho-socialaspects showed a narrow correlation with ap-pearance and the course of back pain. On thecontrary, no significant connection was foundbetween back pain and smoking.

The information of the Styrian back pain report is an inalienable constituent part of a responsible health care policy and offers a tech-nical basis for the paradigm change in the current growing scarcity of financial resourcesin health care systems. This change demands political courage. It is necessary to denouncethe prevalence and incidence of back pain bymore state-of-the-art and effective methods,on the one hand by prevention measures andon the other hand by new interdisciplinarymethodological approaches of pain treatmentto enhance efficacy. At least our common mainobjective must be to reduce the burden of peo-ple suffering from chronic back pain.

Ewald Gspurning

55

Dr. Galileo GuidiRegional Commission for the Coordination ofthe Action in the Fight Against PainCoordinator of the Interregional Work Groupon Palliative Care

Pain herapy and palliative care in TuscanyIn a 2001 modification to the Italian constitu-tion, the organization and administration ofhealth care services were delegated to the re-gional governments. This change placed theresponsibility of pain therapy and palliative careon the shoulders of the regional health caresystem. The Tuscan region has confronted theproblem of pain therapy and palliative care inits Regional Health Plans with a policy that fur-nishes organisational guidelines for the servicesthat have been instituted in all the local healthauthorities.

This policy for the development of a networkfor the palliative care, including paediatric pal-liative care, has been defined and adopted. Thiscourse of action permitted not only the com-pletion of residential centres (hospices), butalso, in coherence with the national programand financing, the integration with the territorialhome care services. Furthermore this policyendorsed a project “Pain free hospital” thathas been introduced in all the hospitals in theregion. The regional government also instituteda commission for the “Coordination of the fightagainst pain”, composed of professionals, ad-ministrators and public representatives withthe mandate to promote and coordinate allthe activities related to the fight against painand to monitor the indicators implemented bythe region as stipulated in the regional healthplan. The region has also adopted, within thelimits of the organizational autonomy foreseenby national law, specific action to promote theuse of opiates.

The Tuscan Region has approximately 3,6 mil-lion inhabitants, 12 local health authorities and4 academic university hospitals.

In all the local health care authorities a func-tional unit for palliative care has been activated.Furthermore 22 hospices have been planned,of which 17- including 1 paediatric hospice -are operational with a total of 125 active beds.There is also 30 active outpatient pain units inthe Tuscan region.

The region is also constantly monitoring theindictors identified in the fight against pain incollaboration with the Regional Health Agencyand the Sant’Anna School of Excellence. Thetwo indicators that form part of the regionalevaluation of the performance of the localhealth authorities, and were identified, are theconsumption of opiates and the registration ofthe parameters of pain in the clinical recordsof patients admitted to hospital.

The results obtained in Tuscany can be sum-marized as follows: •The consumption of opiates (national data ob-

tained from SFERA) increased from 0.15DDD/1000 inhabitants in 2001 to 4.15 in2009. This represents an opiate consump-tion of almost double the Italian national average of 2.41 DDD/1000 inhabitants.

• In 2009 the per capita consumption of morphine in Tuscany were 4.1 mg. A studyof the clinical records of the hospitalised patients shows that pain parameters wereregistered in 49.6% of the clinical records.

Galileo Guidi

56

Magdi Hanna MD

Director of Analgesics & Pain Research Unit (APRU)

APRU

PO BOX 22

BECKENHAM

KENT, BR3 1UR

ENGLAND, UK

TEL/ FAX:00442083256473

MOBILE:0044778525560

EMAIL:[email protected]

Magdi H. Hanna became Director of the Pain Research

Unit (PRU) at King’s College School of Medicine in London

(UK) in 1985. Since then he has been an Honorary

Senior Lecturer at King’s College School of Medicine

and Dentistry,

Director of the Pain Relief Unit and Consultant in Pain

Medicine at the Department of Anaesthesia, Intensive

Care and Pain Relief at King’s College Hospital, London.

He became the Clinical Director of PCRH (Pain Clinical

Research Hub), a collaborative academic research unit

at King’s College School of Medicine and Pfizer in 2003

that specializes in developing pain biomarkers for chronic,

nociceptive and neuropathic pain states.

He has been Member of the European Academy of

Anesthesiology, European Association for Palliative Care

(EAPC), International Association of the Study of Pain

(IASP) and the British Pain Society for the last 25 years.

He has published extensively on the subject of pain, and

has been an invited speaker in numerous pain and

anesthesiology meetings, both nationally and interna-

tionally.

Currently a Consultant in Pain Medicine in the Independent

Health sector and the Clinical Director of the “Analgesics

&Pain Research Unit” (APRU) which acts as an inde-

pendent advisory unit for the pharmaceutical industry

and research units on drug development, use of human

pain models, translational research and Phase II clinical

studies as well as conducting due clinical diligent and

registration filing advice. He is a member of “Pain

Medicine Teachers” group and is on the Faculty of the

1st EFIC school for “NEUROLOGICAL DIAGNOSIS IN

CHRONIC PAIN”.

The Social Costs of Painful Diabetic Neuropathy

The dramatic increase in newly diagnosed cases of type

2 diabetes is a major public health concern within the

European Union.

It has been estimated that up to 50% of people with

type 2 diabetes will develop a degree of neuropathy

(Boulton, 2005). At least 20% of those affected are

likely to suffer from chronic neuropathic pain. The

majority of PDN patients experienced constant moderate

to very severe pain. In addition to the pain itself, there

are associated high levels of co-morbidity and related

symptoms, including difficulty sleeping, depression, and

anxiety. This has led to significant impairments in quality

of life (Benbow et al, 1998; Galer et al, 2000). PDN is a

clear area of unmet clinical needs. Currently there is no

effective therapy to treat, prevent or reverse the neu-

ropathy once it has been established. The goals of

available therapies are: pain, symptom control, a reduction

of co-morbidity and an improvement in quality of life. Tra-

ditionally antidepressants, anticonvulsants, and opioids

have been the main compounds used for pain control in

PDN patients. Newer agents, such as SNRI (eg duloxatine),

�2� ligands (gabapentin, pregabalin) have been found

to have proven efficacy in treating PDN. However, all of

these compounds have less than 50% responder rate

and most patients are left with significant residual pain.

Adverse side effects are a considerable hurdle for

patients, particularly sedation and weight gain. Overall

the quality of PDN treatment appears to be poor, with

few patients receiving recommended medications in ef-

ficacious dosages.

Though knowledge of the health care costs associated

with neuropathic pain is somewhat limited, recent

studies have identified that PDN has the highest additional

health care costs even in comparison with other painful

neuropathies such as postherpetic neuralgia (PHN)

(Dworkin RH 2009). The substantial cost to society of

PDN derives from direct medical costs, loss of the

ability to work, loss of caregivers' ability to work and

possibly greater need for institutionalization or other

living assistance (O’Connor AB 2009 ).

The cost of managing painful diabetic neuropathy can

increase the basic cost of managing diabetes by two

and up to 10 fold depending on the degree of associated

co-morbidity such as anxiety and depression (Boulanger

L 2009).

It is hoped that better understanding of the economic

burden of PDN will provide a basis for evaluating the im-

pact on health care costs of new interventions for their

treatment and prevention.

Magdi Hanna

57

Prof. Per Hansson, MD, DMSc, DDSProfessor of Clinical Pain ResearchDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm&Senior Consultant and Section Head, Pain CenterDepartment of Anaesthesiology and Intensive CareKarolinska University Hospital (Solna)StockholmSweden

Per Hansson is professor of clinical pain re-search at Karolinska Institutet and a specialistin neurology and pain medicine at the Karolin-ska University Hospital in Stockholm, Sweden.Professor Hansson is head of and a senior con-sultant at the Pain Center, Department ofAnaesthesiology and Intensive Care, and headof Clinical Pain Research, Department of Mo-lecular Medicine and Surgery at Karolinska In-stitutet. He received his dental and medicaldegrees from the Karolinska Institute in 1979and 1986, respectively, and his PhD in physiol-ogy at the same institute in 1985. He was ap-pointed associate professor of physiology in1991 and professor of clinical pain researchin 2000.

Peripheral and central neuropathic pain, somato-sensory testing, endogenous pain con-trolling systems and functional brain imagingrepresent major areas of interest in ProfessorHansson’s research.

Professor Hansson is a reviewer for many sci-entific journals and has served as co-editor ofPain Reviews, on the editorial board of Pain,Clinical Updates and is currently field editor forclinical medicine/neurology of the European

Journal of Pain. He has published close to 150journal articles and book chapters, and haslectured at numerous conferences and sym-posia worldwide. He is co-editor of 2 bookspublished by the IASP Press.

Per Hansson is a member of several profes-sional societies such as the International As-sociation for the Study of Pain and has servedas scientific secretary of the Swedish Societyof Algology and as scientific advisor to theSwedish Medical Product Agency. From 2003-2006 he was president of the ScandinavianAssociation for the Study of Pain. He is cur-rently Honorary Secretary of the European Fed-eration of IASP Chapters.

Per Hansson

58

Prof. Yves HenrotinDirector of the Bone and Cartilage ResearchUnitUniversity of Liège (Belgium)

HENROTIN Yves is Professor of Physical Ther-apy and Rehabilitation and director of the Boneand Cartilage Research Unit at the Universityof Liège (Belgium). He is also an administratorof the Centre of Immunology (CIL) and the Cen-tre for Oxygen Research and Development(CORD). He has been head of the Physical Ther-apy and Rehabilitation department at thePrincess Paola Hospital, Marche-en-Famenne,Belgium, since 1991. He is a member of theAmerican College of Rheumatology, the Osteoarthritis Research Society International,the French Society of Rheumatology and theInternational Cartilage Repair Society. He hasbeen a member of the board of directors andchairman of the communication committee ofthe Osteoarthritis Research Society interna-tional (OARSI) since 2006. Recently, he hasbeen elected treasurer of the OARSI. He is alsoa member of the administrative council of Spineand osteoarthritis sections of the French Soci-ety of Rheumatology. He has represented Bel-gium at the management committee of theCOST B13 action. He has been president ofthe Belgium Back Society since 2002 and vice-president of the Belgium Scientific Society ofPhysical Therapy since 2008. He is a memberof the board of the National Council of PhysicalTherapy and Rehabilitation for the BelgiumHealth ministry. He serves the editorial boardof several scientific reviews including “Os-teoarthritis and Cartilage”. He has been asso-ciate editor of the BMC musculoskeletal disor-ders since 2009. He has published over 150scientific peer-reviewed papers and 10 chap-ters of book and was the co-editor of the book

“Osteoarthritis: clinical and experimental as-pects”. Recently, he has received a prestigiousnational prize (De Cooman Prize) for his contri-bution in the better understanding of os-teoarthritis pathophysiology.

Yves Henrotin

59

Drs. Jacob HofdijkImplementation of Integrated Funding ChronicDisease (Dutch ministry of health)President EFMIPartner in Casemix

Jacob trained at the Rijks UniversiteitGroningen (1974) in Doctoral BusinessEconomics mainly focussing on systemsapproach and informatics. In May 1974 hestarted his career in Health Care at theUniversity Hospital Leiden with thedevelopment of the BAZIS Integrated HospitalInformation System. He played a role inbridging between hospital management,clinicians and service departments with ITdevelopers. In 1979 he became projectmanager of the first DRG project in theNetherlands. This was the start of hisinvolvement in the paradigm shift of healthcare management. Together with Prof JM.Rodrigues, he started the InternationalNetwork for Patient Classification Systems(PCSE), which is still the only internationalnetwork for health care management strategybased on Casemix tools.

Since 1990 he has been a member of the EFMIcouncil and board. He has served from 2008-2010 as president of this federation.

In 2005 he left HISCOM to be more active inthe world of Casemix in the Netherlands, as apartner in Casemix, as a consultant at theMinistry of health and special advisor of theDutch Casemix office (DBC Onderhoud). Since2006 he has become involved in theapplication of Casemix tools on chronic diseasemanagement for diabetes care to support theZonMW experiment.

At the Dutch Casemix organization he playedan important role in the design of the secondversion of the DBC system "DOT". At thebeginning of 2009 he left DBC Onderhoud tojoin the project team of the introduction of theintegrated funding system at the Ministry ofHealth. In this position he is active in creatinga base for supporting IT solutions forintegrated health care delivery based on carestandards. Annex to the care standards arecommon agreed obligatory parameters(modelled as Detailed Clinical Models) andsystem requirements for integrated caresystems. Since 2006 he has been involved in a study ofthe Ministry of Health and CF centres toimprove the integrated care for cystic fibrosispatients. The study of all costs of this raredisease has resulted in a model for integratedfunding, which will be tested soon.

Jacob Hofdijk

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Prof. Morten HjulsagerHead of Department,Monitoring & Health Technology AssessmentNational Board of Health, Denmark

The presentation will focus on economic evalu-ation in dealing with broader analysis of paintreatment. This is done through

1) Discussing the role of health technologyassessment (HTA) as a methodologicalframework for analysis

2) Presenting two Danish cases of HTA in thearea of pain treatment.

Health technology assessment (HTA) is a sys-tematic, research-based approach to analysingspecific technologies. A primary strength ofHTA is the broad approach. The analyses en-compass four very different key elements of:technology, patient, organisation and economy.In that sense HTA is based on several scientificdisciplines which enable the synthesis to reflectmore sides to the issue at hand.

The presentation includes two specific casesof HTA dealing with the subject ‘pain’. An HTAon the Multidisciplinary Pain Centre at HerlevUniversity Hospital which has offered a cogni-tive-behavioural group treatment (called PainSchool) to patients with chronic non-malignantpain. And an HTA on postoperative pain treat-ment after outpatient foot surgery.

Morten Hjulsager has a master in economics,and works in the Danish National Board ofHealth. Head of department since 2001, cur-rently with responsibility for health monitoreringand health technology assessment. This in-cludes quality measurement, evaluations andtechnology assessments of health policy issues.Mr. Hjulsager has worked intensively with documentation in the health care sector, earlierwith responsibility for the Danish national health

registries. Mr. Hjulsager is also an associatedprofessor at the University of Copenhagen, de-partment of Economics.

Morten Hjulsager

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Prof. Dr. Wilfried Ilias Dept. of Anaesthesiology Intensive Care med. & Pain TherapyAcademic Teaching Hospital St. John of God;A-1020 Vienna, Johannes v. Gott-Platz 1

Social Impact of Chronic Pain in Austria,Facts and Solution Strategies

One of the measures of the social impact ofpain may be the number of individuals who haveto go into early retirement because they arehandicapped by chronic pain. As to official dataof 2007 one third of these individuals are suf-fering from chronic pain, another third fromdepressive disorders as the underlying disease(1). It is well known that both problems appearvery often in combination. Other measures ofcourse are official statistics on pain relateddisorders and the use of analgesics as well,both statistics show a steady increase (2). A recent patient evaluation in 565 chronic painpatients showed that most of them had seenmore than two doctors within the last 3months before the evaluation in order to re-ceive an adequate diagnosis and treatment (3).The most common reasons for chronic painwere degenerative diseases of the skeletal ap-paratus 81% males and 79% in females. Infor-mation by doctors (94%) was judged the mostimportant source concerning the individual painproblems followed by other sources such asnewspapers (31%), friends (16%) and relatives(15%). In reaction to the increasing social im-pact of chronic pain specific postgraduateteaching and training programs have been in-stalled in order to improve the general situa-tion. In Oct. 2009 an official postgraduate train-ing and diploma curriculum on pain initiated bythe Austrian Pain Society was accepted anddischarged by the Austrian Medical Chamber.Also in 2009 the Austrian Federal Institute on

Health installed a taskforce on the treatmentof chronic pain with the purpose of developinginterdisciplinary staffed institutions for the di-agnosis and treatment of patients sufferingfrom chronic pain. Concomitantly there arealso efforts to establish rehabilitation clinicsfor out-patient and in-patient care of individualswho need medical assisted physical trainingand mobilization programs. It has to be men-tioned though that establishing new structuresis very difficult in these times, when budgetsare already limited because of the universalcommercial implusion. We are optimistic however that the social andeconomic impact of chronic pain is taken veryseriously not at least because of the currentfinancial crisis. It is meanwhile generally ac-cepted that as also in other degenerative dis-orders prophylactic steps such as physicaltraining, diets, avoidance of smoking and im-provement of working conditions will help toavoid a further increase of individuals who arehandicapped because of chronic pain disorders.

References:Ettinger, K. 2009. Immer junger in die Invalid-itätspension. In Die Presse. Wien: Die PresseVerlags GmbH.Statistic Austria, . Chronische Krankheiten undGesundheitsprobleme 2006/07. Stein, Viktoria, Dorner, T., Ilias, W., Rieder Anita:Schmerzpatienten und ihre Erwartungen an diärztliche Versorgung. admitted for Publicationin „Der Schmerz“

Wilfried Ilias

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Dr. med Eric X. JensenSpecialist in Internal Medicine FMH,Medicolegal Expert SIM & SGVMedical Director Medizinisches ZentrumRömerhof, 8032 Zürich,Switzerland

Medicolegal aspects of chronic paindisorders in the Swiss social insurancesystem

Long term working disability resulting fromchronic pain disorders represents anincreasing burden to the Swiss socialinsurance and welfare system. 16% of all Swisssuffer chronic pain and every sixth of them areunable to work therefore. 2006 the direct andindirect costs related to working disability inSwitzerland summed up to 25-30% of thenational gross domestic product. Meanwhileover 50’000 persons in Switzerland areentitled to a disability pension, representing aglobal amount of 5.5 billions of Swiss Francsper year. In about 12% of all cases pain isdirectly associated with the work occupation,affecting mostly the musculoskeletal system(lower back in 55%, shoulders in 48%, upperlimbs in 36%, lower limbs in 31% and the neckin 22% of all cases). Chronification of pain isoften related to social und contextual factorssuch as poor education, monotonous and/orstrenuous work, fear of disease, low motivationto return to work resulting from negativefinancial incentives, but also to medical factors such as inappropriate diagnostic ortherapeutic workup and management as wellas inadequate long sick leave leading with timeto physical (and mental) deconditioning. Thechances of successful work reintegration

diminish dramatically with time, being of lessthan 18% after one year off work. Theassessment of working eligibility in Switzerlandbases on legal considerations, about what canbe reasonably expected from patients withchronic pain disorders. Recognized reasons fora reduced working capacity are security issues,objectively impaired physical or intellec-tual performance, risk of further healthdeterioration or psychiatric comorbidities. Theevaluation is however problematic in cases ofchronic pain without any somatic origin resp.detectable organic lesion such as in chronicsomatoform pain disorder, fibromyalgia,chronic fatigue syndrome etc. In these casesthe Swiss medicolegal system has establishedspecific criteria (such as presence of othersevere physical or psychiatric comorbidities,proven therapeutic resistance to standardtreatment, social isolation etc.), which must befulfilled, to entitle the patient to financialcompensation.

Eric X. Jensen

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Dr. Werner KerschbaumDeputy Secretary GeneralAustrian Red Cross

Symposium on Societal Impact of PainAbstract: “Carers’ Association”

At present, pain is not adequately treated. Oneissue in this connection is that patients suffer-ing from dementia do not receive adequatetreatment due to difficulties in pain assess-ment. This pertains to pain therapies in all set-tings of medical treatment and nursing: in hos-pitals, in private practices and in nursinghomes. This important issue of health and well-being has not been receiving the attention itdeserves to this day.

The specific situation of informal caregivers’has also not been receiving adequate attentionalthough they play an important role within thehealth system. Family members provide a sub-stantial part of assistance, care and nursingservices, but their enormous work is not suffi-ciently perceived and appreciated. Besides this,the provision of informal care competes withother priorities of a carers’ life (e.g. his or hercareer). Caregivers’ health suffers from physi-cal, social and mental burden caused by long-lasting informal care.

In order to improve the situation of informalcarers, the Austrian Red Cross is about tofound “Carers’ Association”. The need to giveinformal carers a strong voice was the resultof profound discussions with informal carers,self-help groups, public and private insurancecompanies and other stakeholders such as thepublic sector and research institutions.

To help improve the situation of informal carers,the planned association will encourage the de-velopment of measures like education, infor-mation and training, day-care facilities, providingmore flexible care as well as more and afford-able short-term-care facilities. Important tasksof this new association will be lobbying and ad-vocacy among decision makers in the publicand private sector. Another important role willbe to work towards raising awareness for thesocial relevance of caregiving and ensuring thatcaregivers’ important role shall be appreciatedand rewarded. Also, informal caregivers will beempowered to represent themselves and theirown concerns. Furthermore, the Carers’ As-sociation will provide information about existingservices and network structures. Additionally,it will serve as a contact point for caregiversand their concerns. Aims are to make care-givers’ work visible, harmonize services and of-fer comprehensive information on provisionsand services as well as contributing to a bettercompatibility between informal care and career.Furthermore the Carers’ Association supportsthe annual assessment of the Austrian careallowance. Also, the association will advocatea more efficient assessment of pain and theprovision of adequate therapies.

The Austrian Red Cross initiated the Carers’Association and will support it in establishing anation-wide structure with regional delegates.Furthermore, it will help carry out public rela-tions work with the aim of making the publicaware of the situation of informal caregiversas well as gaining members.

Werner Kerschbaum

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Prof. Paul KindCentre for Health EconomicsAlcuin CollegeUniversity of YorkYork YO10 5DDUK

Measuring the value of pain in economicevaluationNational regulatory agencies increasingly relyon evidence of cost-effectiveness. At the heartof this economic analysis is the fundamentalissue as to whether the additional benefits of anew therapy outweigh the additional costs ofproviding it. Economists take a strict view ontwo key questions – HOW such benefits shouldbe measured and WHO should be asked tomake those measurements.

This workshop will briefly summarise theprocesses involved and identify the strengthsand weaknesses of the economist’s analyticapproach.

BiosketchPaul Kind has a background in economics,psychology and computer science. Hisresearch career dates back more than 30years and has centred primarily around thedevelopment and application of health statusmeasures for use in clinical and economicevaluation. Paul combines his academicresearch with consultancy in the field of health-related quality of life, both within the NHS andthe international pharmaceutical industry. Heis a Professor of Health Economics in theCentre for Health Economics at the Universityof York. He has held similar visiting positions inthe Department of Pharmacy, University ofUppsala, Sweden, McGill University, Montrealand the University of Wisconsin, Madison. He

has been a Faculty Member of the NetherlandsInstitute for Health Sciences ErasmusUniversity, Rotterdam and an Honorary Fellowof the National Centre for Quality of LifeResearch, St. Petersburg and has served asan elected member of the Board of theInternational Society for Quality of LifeResearch (ISOQOL) and as SIG leader for theInternational Society for Pharmacoeconomicsand Outcomes Research (ISPOR). Paul iscurrently an elected member of the Board ofISPOR. A Founder Member and past-Presidentof the EuroQoL Group, he Chairs its ScientificExecutive Committee.

Paul Kind

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Prof. Jos Kleijnen, MD, Director, Kleijnen Systematic Reviews Ltd, York,UK.www.systematic-reviews.com

Literature review about the epidemiology ofchronic pain in 8 European countries and Eu-rope as a whole.

Chronic pain is very common but good dataare scarce about the prevalence, incidence, diagnosis, severity, treatment, utilization ofhealth care, and the impact of chronic non-can-cer pain on society, health care systems andthe patient.

Information about the epidemiology of chronicpain can help health care professionals as wellas decision and policy makers decide abouthealth budgets and prioritization, patient seg-menting and budget fencing, and therapy budg-ets, including behavioural therapy and drugbudgets.

This presentation aims to provide epidemiolog-ical information about chronic non-cancer painin Europe using the most representative, re-cent, comprehensive and valid studies. We havereviewed the literature about 21 different ques-tions relevant to chronic pain for each of thefollowing countries: Germany, UK, France, Italy,Spain, Sweden, Denmark, the Netherlands, andEurope as a whole.

The questions that we addressed ranged fromwhat is the prevalence and incidence of chronicpain, what are the underlying diseases, whatare the treatments used, what is patients’ com-pliance and satisfaction, to what are the costs

of chronic pain? More than 1000 individualstudies were included, and the results pre-sented in reports for each country.

This presentation will give some snapshots ofthe most interesting findings: there is a tremen-dous amount of information about chronic painin Europe, and the vast majority comes fromthe specific countries. A lot of data/studiesexist, but far fewer studies addressed a repre-sentative general chronic pain population, sosome care in interpretation is warranted.Prevalence of chronic pain is high in Europe(12-26%). Mean annual costs per annum perchronic pain patient are typically several thousand euros, increasing to low 5-figuresums from societal perspectives.

Jos Kleijnen

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Harry KletzkoVizepräsidentDeutsche Schmerzliga

Deutsche Schmerzliga e.V. - German PainLeague

Mission-statement: The mission of the “Deutsche Schmerzliga” isto improve the situation and life of pain patients.Above all, this means improving the generalframework of health care policies (legislator,sickness insurance funds) and opening up ther-apeutic channels for patients suffering fromchronic pain.

The Deutsche Schmerzliga is calling for: • Recognition of pain as a symptom in itself• Exemption of chronic pain patients from pre-

scription fees• Off label channel of prescription• No “aut idem” application to chronic pain pa-

tients• Satisfaction of the legally founded claim to

pain therapy• Lifting of restrictions for the treatment of

chronic pain patients• Qualified training of pain therapists, quality

assurance

The “Deutsche Schmerzliga”, founded in 1990,is a non-profit and non-governmental organiza-tion with more than 5,500 members; most ofthem are chronic pain patients themselves. Itis the largest chronic pain patient organizationin Germany and runs almost 110 regional self-help groups. Activities: Our organization `s aims are to beachieved through the following ways:

• Formation of regional, manageable self-helpgroups, the members of which are given pro-fessional guidance, both as group and on anindividual basis.

• Broadening knowledge about the variousforms of pain therapy available.

• Public relations with the aim of igniting andwidening the interest and understanding ofthe general public for pain diseases, pain pa-tients and pain therapy.

• Furthering science and research in pain ther-apy.

• Establishment of interdisciplinary and bothnational and international contacts and linkswith other associations, organizations, self-help groups, medical doctors, pharmacistsetc.

• Provision of updated documentation on thelatest insights into pain therapy in an easilyunderstandable form for the non-profession-als.

Contact details:Deutsche Schmerzliga e.V.Adenauerallee 18D-61440 OberurselGermanyTel. + 49 (0) 700/ 375 375 375Fax + 49 (0) 700/ 375 375 [email protected]

Harry Kletzko

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Dr. Phil. Albrecht KloepferBureau for communication in health politics

Albrecht Kloepfer studied Musicology and Ger-man Literature in Paris and Berlin. From 1987to 1999 he taught history of German literatureas an academic assistant at several universi-ties in Berlin and Tokyo. From 1996 to 2001,he worked as a journalist and editor for themagazine “Deutschland“ for German Ministryof Foreign Affairs.

Since 2001 Dr. Kloepfer has been focussingon public relations, event management, lobbyingand strategic communications for enterprisesand associations in health care and publichealth. He also is publisher of “Letters onHealth Policy,“ a weekly news summary of Ger-man health policy, and as a publisher and mod-erator he is well known in health political circlesin Germany and in the German speaking EU.Currently in Berlin’s Hotel Adlon, Dr. Kloepferhosts the weekly “Health policy round tables”as well as regular round tables in Brussels. Asa moderator Dr. Kloepfer brings the differentstakeholders in the health care system to-gether in public events, closed meetings andmanaged care projects.

Dr. Albrecht Kloepfer and painVoluntarily engaged in raising funds for a resthome for elderly persons Dr. Kloepfer is verywell aware of the day to day challenges relatedto the sociatal impact of pain. Professionallyhe is engaged with the Association for PainSpecialist in Germany (BVSD).At the symposium “sociatal impact of pain” Dr. Kloepfer will have 2 functions. He will assistthe EFIC president Prof. Varrassi in the mod-eration of the plenum sessions and will moder-ate one of the workshops. After the symposiumhis team will realise the symposium proceed-ings based on the outcomes of the symposiumand workshops.

Albrecht Kloepfer

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Prof. Dr. Norbert KlusenCEO of Techniker Krankenkasse, Germany

Pain and pain therapy is a topic of increasingrelevance in European societies and partly dueto increasing workload and stress. Accordingto findings the Techniker Krankenkasse (TK), alarge German insurance fund, one in ten sickleave days of German employees are causedby serious back pain, and two thirds of the Ger-man population are reported to suffer at leasttemporarily from headaches. The data showthat even a worrisome number of children isaffected: one in two pupils at primary schoolsuffer from tension headache or migraine. Thus, a crucial element and indicator for thequality of a patient-oriented health care systemis the provision of quick access to appropriateand effective structures of pain therapy. Foroptimal results in pain therapy broad accessto efficient medication has to be accompaniedby interdisciplinary and coordinated structuresof managed care. Successful managed caremodels for pain therapy have to comprise multimodal concepts of pain treatment, struc-tures encouraging active patient participation,and coordinated treatment structures in aninterdisciplinary network.Various managed care plans of TK combinethese requirements for interdisciplinary paintreatment successfully. In different models ofintegrated care TK provides co-ordinated multimodal pain therapy for back pain and mi-graine in regional networks. Treatment plansare flanked by programs promoting active patient participation, e.g. by stimulating virtualdialogues in order to facilitate communicationbetween doctors and patients with low backpain, or by giving patients the opportunity for asecond expert's opinion prior to spine opera-tions. The success of managed care conceptsin pain therapy relies heavily on well-functioningcooperations between insurance companiesand involved health care professionals, i.e. doc-

tors of various qualifications and therapists.After a first analysis of both medical treatmentsituation and patients' wishes, treatment pa-rameters and coordinated paths have to bedeveloped together and put into practice ac-cording to patients' needs. Experiences showthat coordinated models work best if they arefocused on limited geographic regions and al-low individualized pain treatment programs. Even though there is no doubt about the needof coordinated care concepts in pain therapy,the concrete benefit and cost-effectiveness-re-lation of managed care plans have to be evalu-ated by supporting health care research. Fu-ture progress in health care research by paincooperations will depend on the disposition ofthe partners to bring together their varyingideas on methodical issues like data design andevaluation parameters.Limited financial resources continue to be acentral challenge for health care supply in al-most every country. This has become an evenlarger challenge in Germany since a centralhealth fund has been introduced which givesinsurance companies even less financial roomfor making investments in innovative managedcare concepts and health care research. Fu-ture concepts and research in pain therapywill largely rely on the ability of the cooperatingpartners to find ways of generating the neces-sary resources.

Graduated in Business Management and PhDin Economics; President and Chief ExecutiveOfficer at the Techniker Krankenkasse (TK), aleading German health insurance company;Professor of International Health Care Policyand Systems at Leibniz University Hanover,Professor of Health Care Economics andHealth Care Policy at the University of AppliedSciences of Western Saxony, Visiting professorat the University of Michigan and FirstExecutive in residence of Griffith LeadershipCenter for Health Management and Policy, AnnArbor, USA (2009)

Norbert Klusen

69

Prof. Hans G. Kress MDPresident Elect of EFIC

Chairman: Dept. of Special Anaesthesia andPain TherapyMedical University / AKH ViennaVienna, Austria

Hans Georg Kress is Professor of Anaesthesi-ology, Intensive Care and Pain Medicine andHead of the Department of Anaesthesia andPain Therapy at the Medical University / AKHVienna . Professor Kress earned his MD andPhD degrees in Germany. He is certified by theAustrian and the German Board of Physicians,with added qualifications in Pain Management,Critical Care Medicine, and Emergency Medi-cine.

He is President Elect of the European Federa-tion of IASP Chapters (EFIC). He was foundingchairman of the Task Force on Pain Manage-ment for the Austrian Society of Anaesthesiol-ogy, Resuscitation and Intensive Care Medicine,and past president of the Austrian Pain Society.He was a co-founder and executive board mem-ber of the Austrian Society for Palliative Careand President of the 11th European Associa-tion of Palliative Care (EAPC) congress 2009in Vienna.

Professor Kress is Deputy Editor of the Euro-pean Journal of Pain (EJP) and was a co-editorof Acute Pain . He has authored numerous sci-entific articles, books and book chapters. Hismultiple clinical and experimental research in-terests include pharmacological treatment ofacute and chronic cancer and non-cancer pain,invasive pain therapy and neuromodulation, andpharmacology of anaesthetics, opioids andcannabinoids.

Hans G. Kress

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Marja R. Kuijperspharmacist, advisor Dutch Health CareInsurance Board (CVZ)

For the past five years she has been intensivelyworking on policy aspects of treatment with,and reimbursement of, expensive medicines.On behalf of CVZ she initiated the developmentof the procedure of assessing expensivemedicines, in order to be able to advise theDutch Health Authority (NZa) on payment forexpensive and orphan drugs in hospitals. Shehas been involved in a project which has strivento develop guidelines for observationalresearch (outcome research) for innovative,expensive medicines. For the past two yearsshe has, on behalf of CVZ, directed researchon off-label use of innovative, expensivemedicines, especially oncolytics. On the basisof the results she wrote a policy report aboutoff-label use of medicines from thereimbursement perspective. She was editor ofthe Medical Aids Compass of CVZ (list ofreimbursed medical aids, 5 volumes publishedbetween 2002-2005). She is currentlyworking on a CVZ report on off-label use ofmedicines from the perspective of health careinsurance.

Marja R. Kuijpers

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Prof. Paul C Langley Adjunct Professor, University of Minnesota

THE IMPACT OF PAIN ACCORDING TO CONSUMERS AND PATIENTSRESULTS OF A SURVEY IN THE BIG 5 EUCOUNTRIES

The societal impact of pain in Europe is pro-found. The results of a recent analysis of the2008 National Health and Wellness Survey forthe five big EU countries point to the negativeimpact of pain on health related quality of life(HRQoL), employment status and productivityand health care resource utilization. Overall, 1 in 5 of the population of the 5 EUcountries reported pain in the last month – anestimated 51.8 million persons. Severe painwas reported by 21.8%. Combining pain sever-ity and frequency, an estimated 21.8 million re-ported daily pain with 8.5 million reporting se-vere daily pain. This amounts to almost 9% ofthe big 5 EU population. The survey reports onthe key conditions associated with pain (backpain and joint pain) and with those comorbidi-ties most closely associated with pain severity.The NHWS also reports on medication utiliza-tion, both prescription and OTC for pain. Opioiduse is not only strongly related to increasingpain severity, but medication compliance is alsohighest with opioid use. The presence of painis associated with significant health relatedquality of life deficits. This is seen in the deficitsassociated with both SF-12 and SF-6D scores.From a multivariate modeling, the presence ofsevere pain reduced SF-6D utilities by -0.164(scale 0 – 1) and severe and frequent pain by-0.186 compared too persons reporting nopain. At the same time, the presence of severedaily pain had a significant impact on increasedabsenteeism (odds ratio 8.094) and increasedpresenteeism (odds ratio 7.319). Finally, severe

and frequent pain resulted in increased utiliza-tion of physician visits (145.4%), emergencyroom visits (194.1%) and hospitalizations(263.1%). Overall, the experience of pain im-poses an unequivocal and substantial societalburden and represents a substantial publichealth issue in all five countries. The analysis confirms previous assessmentsof the prevalence and correlates of pain. Moreimportantly, in comparing both pain and non-pain populations, this analysis provides for thefirst time a comprehensive and consistentquantitative assessment of the various dimen-sions of the societal burden of pain. It points tothe fact that the burden of pain is a function ofboth the severity and frequency of pain experi-ence. These two dimensions of pain, notablythe daily experience of severe and moderatepain, typically dominate multivariate assess-ments of the correlates of HRQoL deficits, lostworktime and productivity and increased health-care resource utilization.

Paul C Langley

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Dr. Pete MackenzieScottish Government Lead Clinician for ChronicPain

DEVELOPING A NATIONAL SERVICE FRAMEWORK FOR CHRONIC PAIN

It is an honour to be asked to speak at this in-teresting and important meeting. The reason Iam speaking is that I was appointed as ScottishGovernment Lead Clinician for Chronic Pain inMay 2009. My talk will explain how NHS Scot-land health planners were persuaded to sup-port improvement plans for chronic pain, up-date the audience about agreed plans, considerrisks to progress and describe next steps.

How was support agreed with the ScottishGovernment and NHS Scotland?The Scottish Government appointed a lead cli-nician for chronic pain because of strong stake-holder support for the priority actions of theGetting Relevant Information on Chronic PainServices (GRIPS) report published by the health-care watchdog NHS Quality Improvement Scot-land (NHS QIS) at the end of 2007. The net re-sult has been enhanced recognition of chronicpain within Long Term Conditions workstreams,Scottish Government Health Directorates(SGHD) and NHS Scotland generally. I have alsobeen appointed as a specialty adviser onchronic pain to the Chief Medical Officer. A keybreakthrough happened in December 2009when a proposed service model and cost-effectiveness case was fully supported by the

Director of Healthcare planning, the nationalclinical lead for Long Term Conditions and theRegional Planning Chief Executive Sub-group.

Agreed plansMay 2009 Scottish Chronic Pain Steering Group estab-lished

November 2009 National service review completed December 2010Service model agreed by stakeholders at a na-tional meeting Links between service models for chronic painand musculo-skeletal services agreed Key agreement with Regional Planning ChiefExecutives sub-group January 2010NHS Education for Scotland commissioned Pri-mary Care Learning Needs Assessment andsupported development of an on-line trainingpackage Full project support from NHS Quality Improve-ment Scotland confirmed Support from Information Services Division con-firmed

Risks to progressLack of equity in health board investment inservice and improvement modelsQuality Improvement framework not defined.

Key next stepsA meeting with all health board Chief Executivesin NHS Scotland is planned in March 2010 todiscuss implementation of the agreed servicemodel. NHS QIS has embarked on a process to publishan improvement plan for chronic pain.

Key messagesPeople with chronic pain benefit if their condi-tion is recognised in strategic planning. Healthcare planning benefits from an agreed,evidence based service model.

Pete Mackenzie

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Villy Meineche-Schmidt MD, DMSci

The Private Pain Clinic

Herlev, Denmark.

SOCIETAL BENEFIT OF MULTIDICIPLINARY REHABILITATION IN CHRONIC NON-MALIGNANTPAIN PATIENTS.

Patients are referred to The Private Pain Clinic, amultidisciplinary pain clinic in primary care, due to a‘waiting time guarantee’, i.e. patients have the rightto choose treatment in private care, if public paincenters cannot offer management within one month.As the waiting time in public pain clinics in Denmarkexceeds one year many patients prefer this privatealternative – the private clinic is obliged to see thepatient within one month. Uncertainty about economy and future working ca-pability is an important part of the bio-psycho-socialcomplex of chronic pain. Some patients will have toreconsider their total life and many will not be ableto go back to previous work. Multidisciplinary inter-vention thus, has to address psychological reactionsand social complications along with pharmacologicaltreatment. The aim of the intervention is to help thepatient’s acceptance of future possibilities and limi-tations, focus on new aspects of life with chronicpain and realize that a process of grief may be nec-essary. An essential goal is to secure adherence tothe labour market - if at all possible. Tailored for these patients we developed a Rehabili-tation Program comprising 3 hours per day, 3 timesa week for 13 weeks (120 hours). Each program has10 – 12 participants and comprises group sessionsas well as individual sessions and sessions with par-ticipation of spouses and children. The followingthemes are covered: introduction to the bio-psycho-social understanding of chronic pain, anatomy andphysiology of the human body, principles of physicaltraining and warm water basin sessions, principlesof relaxation therapy combined with personal trainingprograms, psychological aspects of chronic pain andskills for optimizing the use of resources in daily living.Finally, social legislation in relation to the labour mar-ket and social security system and personal assis-tance in relation to the county is offered. The staff inthe program is primary care physicians, psycholo-

gists, physiotherapist, relaxation therapists, socialworkers and nurses.

In this presentation the economic status at thestart of the program and at follow-up 9 monthslater will be reported for the participating pa-tients. The economic impact for society and thecost-benefit of the program is calculated. A total of 117 patients attended eleven rehabilitationprograms during 2007-2009. At the start 23 patients had work income and at fol-low-up, this was maintained by 19 patients, whereasthree patients were on sick pension and one on re-habilitation benefit. 90 patients were on transfer income at the start:thirteen on sick pension, 58 on sick leave, 12 on so-cial benefit and 7 on rehabilitation benefit. Almost allpatients on sick pension maintained this.Of 58 patients on sick-leave, 23 obtained work in-come, 20 sick pension, 6 social benefit, 1 rehabilita-tion benefit – and the remaining six maintained sickleave. Of 12 patients on social benefit, 6 obtained work in-come and of 7 patients on rehabilitation benefit, 6obtained work income. The economic situation was concluded for 97 of 117patients (83%).The Danish social security system divides expensesbetween state and county in a complicated way –depending on the type of transfer income. As a con-sequence of the reported changes, state expensesincreased by 540,000 Euro and county savingsamounted to 698,000 Euro - annually. Thus, the so-cietal savings were 158,000 Euro per year. Totalcosts for the rehabilitation programs amounted to421,000 Euro, thus resulting in balance betweencosts and savings after 2.7 years. The average time to age pension for the participatingpatients was 25 years. The potential accumulated savings thus amountedto more than 3 million Euros.

Conclusions: Patient referral based on waiting time guarantee se-cures early intervention. Only 10 per cent of the pa-tients who participated in the rehabilitation programswere on sick pension at the time of referral (com-pared to 60% in a Danish public pain center), whichfacilitates rehabilitation and return to the labour mar-ket. For patients with unclarified economy at start(sick leave, social benefit and rehabilitation benefit)76% were clarified at follow-up: 45% had work in-come and 31% were on sick pension. The program was highly cost effective: expenses forthe program balanced savings after less than threeyears, while the average time to age pension was25 years. The potential accumulated savings per pa-tient until age pension was 30,000 Euro.

Villy Meineche-Schmidt

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Barbara MilaniTechnical Officer Access to Controlled Medica-tions ProgrammeDepartment of Essential Medicines and Phar-maceutical PoliciesWorld Health OrganizationGeneva

Barbara Milani holds a Masters degree in Phar-maceutical Chemistry and Technology fromthe University of Ferrara in Italy and a postgraduate Diploma in Tropical medicine fromthe Institute of Tropical Medicine "PrinceLeopold" in Belgium. For the past 10 years shehas been working in the area of public healthin different capacities ranging from serving asa front-line pharmacist to advising on procure-ment and supply systems to contributing toessential medicines policy development and im-plementation. She has gained her internationalexpertise working in Africa with NGOs includingMédicins Sans Frontières and later with TheGlobal Fund to fight AIDS, Tuberculosis andMalaria and the World Health Organization(WHO).

In her current role with the WHO Access toControlled Medications Programme she istechnically responsible for managing the de-velopment of WHO's treatment guidelines onpain.

Barbara Milani has recently presented at theInternational Association for Hospice and Pal-liative Care workshop on access to opioids inLatin America in Lima, Peru and served as anorganizer and facilitator of the WHO guidelinesdevelopment meeting on paediatric persistingpain, Rockefeller Conference Center, Bellagio,Italy.

Barbara Milani

75

José María Muñoz y Ramón, M.D., Ph.D.Deputy Medical Director, Chief of Pain Management, Member of the”Hospital SIN DO-LOR” Commttee. Hospital Universitario La Paz,Madrid, Spain

One of the goals of Pain Units is to facilitatethe awareness and collaboration of all profes-sionals in the process of pain relief. However,their daily overload of clinical duties may limittheir activities to the area where they carryout their work. The “Hospital sin Dolor” (PainFree Hospital) Committee is an initiative to re-cruit different professionals and managers tomake pain relief one of the main quality goalsfor the hospital. La Paz University Hospital inMadrid is a 1400-bed teaching hospital with along tradition in education and quality. Withinthe structure for quality management of theCentre, the Pain Committee was created inOctober 2009. It includes 16 doctors from 12medical specialties, 3 nurses and one pharma-cist; at least one member of the hospital man-agement is always present. There is a monthlymeeting, but the main bulk of activities is per-formed within working groups with specific ob-jectives; there are five active workers groups:

1. Epidemiological studies: periodical surveysof the use of pain scales, compliance withpain protocols, and pain prevalence in thedifferent areas of the hospital.

2. Informative documents: elaboration and dis-tribution of pain-related informative leafletsfor patients and health professionals, andcustomized pain scales for children andadults.

3. Educational activities: organization and cred-iting of pain workshops for health profes-sionals, monographic courses and interdis-ciplinary meetings.

4. Research and publications: organization andparticipation in epidemiological studies, clin-ical trials, books, papers and other collabo-rative projects.

5. External communications: relations with thepress, the pharmaceutical industry and sci-entific societies and institutions.

So far, the “Hospital sin Dolor” Committee hasdistributed 5000 customized pain scalesthroughout the hospital, has organized a weeklyinterdepartamental meeting, three workshopson acute pain management and a course ofmusculoskeletal pain. Educational visits and ob-serverships for professionals from other cen-tres have been arranged, and a comprehensiveprogramme for nurses and physicians in train-ing has been set up.

The goal of making pain relief a quality objectivefor the whole hospital has been reached. The“Hospital sin Dolor” Committee has been for-mally integrated in the structure of Total QualityManagement for the Centre.

José María Muñoz y Ramón

76

Laurette A.J. Onkelinxborn October 2, 1958 at Ougrée, Belgium (Ré-gion wallonne), is a Belgian socialist politician.

Graduated in law at the University of Liège, sheis currently residing in Schaerbeek, near Brus-sels. She is Deputy Prime Minister and Ministerof Social Affairs and Public Health in charge ofSocial Integration within the GovernmentLeterme II

Carrière politique • 1987-1995:

députée de la circonscription de Liège (du13 décembre 1987 au 21 mai 1995)

• 1990-1992:vice-présidente de la Chambre desReprésentants

• 1990-1992:présidente de la Commission de la Justicede la chambre des Représentants

• 1992-1993:ministre fédérale de l'Intégration sociale, dela Santé publique et de l'Environnement

• 1993-1995:ministre-présidente du Gouvernement de laCommunauté française de Belgique,chargée de la Fonction publique, de l'Enfanceet de la Promotion de la Santé

• 1995-2000:conseillère communale à la ville de Seraing

• 1995:élue sénatrice (siège du 21 mai 1995 au21 juin 1995)

• 1995-1999:ministre-présidente du Gouvernement de laCommunauté française de Belgique,chargée de l'Éducation, de l'Audiovisuel, del'Aide à la Jeunesse, de l'Enfance et de la

Promotion de la Santé • 1999:

élue députée au Parlement de la Région wal-lonne (siège du 13 juin 1999 au 12 juillet1999) et au Parlement de la Communautéfrançaise de Belgique (siège du 6 juillet1999 au 12 juillet 1999).

• 1999-2003 :vice-première ministre et ministre fédéralede l'Emploi et de l'Égalité des Chances dansle gouvernement fédéral Verhofstadt Ier(elle reprend également brièvement leportefeuille de la Mobilité en 2003)

• mai 2003:élue députée fédérale de l'arrondissementde Bruxelles-Hal-Vilvorde (siège du 18 maiau 12 juillet 2003)

• 2003-2007:vice-première ministre et ministre de la Jus-tice du gouvernement fédéral VerhofstadtII

• 2006:Laurette Onkelinx est donc conseillère com-munale à la commune de Schaerbeek

• 21 déc.2007: ministre fédérale des Affaires sociales dela Santé publique au sein du gouvernementVerhofstadt III.

• 20 mars 2008:vice-première ministre et ministre fédéraledes Affaires sociales et de la Santé publiqueau sein du gouvernement Leterme I

• 30 déc. 2008: vice-première ministre et ministre fédéraledes Affaires sociales et de la Santé publiqueau sein du Gouvernement Van Rompuy I.

• 25 nov. 2009:vice-première ministre et ministre fédéraledes Affaires sociales et de la Santé publiquechargée de l'Intégration sociale au sein duGouvernement Leterme II

Laurette Onkelinx

77

Prof. Ken PatersonChair – Scottish Medicines Consortium

Are We Adequately Equipped to AssessPain Therapies?

Assessment of the comparative effective-ness and cost-effectiveness of healthcareinterventions is increasingly being undertakenas the funds available to provide healthcare areincreasingly stretched. New therapies in thefield of pain are subject to such assessmentand frequently fail to demonstrate that theclinical benefits they bring justify the requiredexpenditure. This may reflect limitations in the therapies, but could also highlight issues with the assessment parameters andmethodologies.

Given that the symptom of pain is widely fearedand has many negative impacts on quality of lifeit is surprising that pain therapies have failedto show cost-effectiveness. It is possible thatlimiting the perspective of health economicassessment to the view of the healthcarepayer misses out on substantial benefits oftherapy, while the absence of prolongation ofsurvival due to the use of purely symptomatictherapy may also limit the potential to showbenefit. Some quality of life assessment toolsmay inadequately capture the benefit of painrelief, especially if this benefit is largelypsychological and does not translate intoimprovements in day-to-day physical activity.

Is pain a special case in terms of healthtechnology assessment …. and if so why, andwhat can we do differently? Do we need newtools, or do those developing and assessingpain therapies need to make better use of toolsalready at our disposal?

Ken Paterson

78

PD Dr. med. Matthias Perleth, MPHAbteilung Fachberatung MedizinGemeinsamer Bundesausschuss

Matthias Perleth studied medicine in Hanoverand Magdeburg (Germany). He obtained a Mas-ter of Public Health degree from the HanoverMedical School. He worked in the departmentof Epidemiology, Social Medicine and HealthSystems Research at Hanover Medical Schoolfrom 1995 until 2001. He acted as head ofthe working unit for Health Technology Assess-ment (HTA) and Guidelines in that Department.From 2001 until 2007 he was responsible forHealth Technology Assessment at the FederalAssociation of a large German sickness fund.Since June 2007 he is head of the Departmentof Medical Consultancy at the Federal JointCommittee (G-BA). His research experiencelies in the areas of Health Technology Assess-ment, evidence-based medicine, guidelines de-velopment, health services research and ef-fectiveness research. He is also president ofthe German Association of Health TechnologyAssessment. He is author of numerous scien-tific articles and books.

Pharmaceutical Pain Care RealityAfter receiving marketing authorisation , drugsare covered by German health insurance aslong as they are not excluded from reimburse-ment. The pharmaceutical market is probablythe most regulated in German health care, butcost increases are nonetheless above the av-erage increase of costs of other services inhealth care. As a matter of principle, drugs arenot covered by Social Health Insurance whenthey are non-prescription drugs (with some ex-ceptions). Lifestyle drugs are excluded too. In

addition, there are a number of regulations re-garding pricing (e.g. reference based pricing),second opinion, off-label use and others. Ger-many is unusual in that the reimbursementlevel on on-patent pharmaceutical products forwhich there are no therapeutic comparatorsis defined according to the list price proposedby the manufacturer without negotiation. Thelatter practice has come under discussion re-cently. Currently, economic evaluation as partof the IQWIG evaluation process of pharma-ceuticals is in preparation. However, on a singlecase basis pharmaceuticals without provenbenefit can be excluded from the benefit pack-age, which has been done in the past (e.g. clopi-dogrel for secondary prevention of myocardialinfarction or stroke or insulin analogues). A keydecision-maker for drug-regulation outside hos-pitals is the Federal Joint Committee (G-BA).The G-BA issues legally binding directives whichcomprise reference-prices for drugs, off-labeluse of drugs, prescription of special drugs, ex-clusion of drugs for certain indications, exclu-sion of life-style drugs and inclusion of drugs inthe OTC exemption list. The requirements ofthe G-BA regarding evaluation of the effective-ness and costs of the new drugs will be dis-cussed.

Matthias Perleth

79

Prof. Ceri PhilipsSchool of Health Science,Swansea University, UK

Pain: the need for a whole systems per-spective

The talk will outline the current evidence onthe prevalence of chronic pain and its impactin terms of its economic costs, including coststo healthcare systems, government depart-ments, employers, patients and societies. Quan-tifying the burden and cost of pain is challengingdue to its multi-factorial nature and wide reach-ing effects, but the relationship between pain,pain relief and quality of life will also be exploredand the gains produced as a result of treat-ment effectiveness will be highlighted.

Pain is a complex bio-psychosocial experienceand chronic pain is a consequence, in part, ofadopting a narrow biomedical treatment ap-proach to a problem which requires a multi-disciplinary approach to address the psycho-social, behavioural and biomedical aspects ofpain. Although effective pain management in-terventions and programmes exist, provisionof these services is inconsistent, and chronicpain is not given the priority it requires in viewof the extent of its burden on individuals andsociety. Current government policies will be dis-cussed to highlight the need to prioritise painand adopt a whole-systems approach to itsmanagement if governments are to success-fully reduce its cost and burden.

It has been strongly advocated that society hasan obligation to reduce levels of pain and re-store normal functioning, based upon bothmoral principles and economic reality. There-fore, it will be argued that pain and its man-agement should be moved higher up in the po-litical agenda and feature more prominently ingovernment policies across all countries. It willbe contended that providing access to effectivetreatments and support is vital, as is ensuringthat the recommendations laid out in govern-ment policies and priorities are evidence-based,contextually appropriate, and are implementedwithin a reasonable timeframe. A joined-up,multi-agency approach is required and gainingthe necessary resources and support from allstakeholders is considered to be essential, in-volving all who have an interest in preventingill-health at work, treating ill-health and rehabil-itating those who have suffered from pain.

Ceri Philips

80

Gina PlunkettVice Chairperson,Chronic Pain Ireland

Charter of Rights for people living with Chro-nic Pain

We have the right to be believed.We have the right to be treated with dignityand respect.We have the right to have our pain treatedand managed at the earliest possible stage.We have the right of access to the best possible technologies and therapies in paintreatment and management.We have the right to be informed about all thepain management options available so that wecan make best decisions and choices for ourwellbeing. We have the right to live with the least amountof pain possible.We have the right to be treated on at least anequal footing with all others who have been diagnosed as having a chronic illness.The Relief of Pain should be declared a funda-mental human right as per the central themeadopted by IASP, EFIC and the WHO at a con-ference in Geneva on the 11th October 2004.We should not be left to suffer in silence andignorance.

Drawn up and approved by the Governing Bodyof Chronic Pain Ireland on the 19th November2009

Gina Plunkett

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Prof. Ian Power BSc (Hons) MD FRCAFFPMANZCA FANZCA FRCS Ed FRCP Edin

Anaesthesia, Critical Care & Pain MedicineCollege of Medicine and Veterinary MedicineUniversity of Edinburgh, Scotland

REAL WORLD DATA TO ASSESS IMPACT OFPAIN; OBJECTIVES AND METHODOLOGYOF ONGOING STUDIES IN THE UK

Real word data is becoming increasingly im-portant in evaluating treatments, interventionsand services within the healthcare sector.Where traditionally new treatments were pre-sented to market with a wealth of randomizedcontrol trial data this, in isolation, is no longersufficient to ensure new treatments areadopted quickly to give access to the patientswho need them most. In addition burden of ill-ness cannot be assessed without the use ofreal world data. In the area of pain manage-ment, patient pathways and treatment algo-rithms are complex and varied and there is aclear need to evaluate current practice in orderto inform improvements where these are pos-sible. A program of real world studies have been ini-tiated in the UK, involving key centres acrossall four countries to collect data on the routinemanagement of chronic pain. The studies arean example of collaborative working betweenthe NHS and the pharmaceutical industry.

The first study focuses on the overall burdenof illness by collecting resource use and path-way data associated with chronic pain fromprimary care practice records. This study will

provide top line data on secondary care re-source use as far as is possible from primarycare sources. However, to supplement this, thesecond study focuses on resource use and pa-tient pathways associated with the same groupof patients within specialist secondary carepain clinics. Both studies were granted centralethics approval in the UK in early 2010 anddata is being collected currently. Further detailson objectives, methodology and interim resultswill be presented and discussed.

Ian Power

82

Prof. Narinder Rawal MD,PhD,FRCA (Hon)Professor of AnesthesiologyDepartment of Anaesthesiology & IntensiveCareOrebro University Hospital

• Professor Narinder Rawal, MD, PhD, FRCA(Hon)

• Graduated from India• In Sweden since 1974• Professor in Anaesthesiology, Department

of Anaesthesiology and Intensive Care,Örebro University

• Visiting Professor: 1)University of Texas, Houston, USA since

19872)University of L'Aquila, Italy since 19993)Benares University, India, since 2008

• Invited as Visiting Professor to about 100institutions

• Original papers over 150• Book chapters and review articles over 90• Books published/edited 15• Member of Editorial Board of over 10

international Anaesthesia or Pain Journals• Awards from over 30 societies/institutions

for distinguished services in teaching ofregional anaesthesia and pain medicineincluding Labat Award (ASRA 2010) and CarlKoller Award (ESRA 2010)

• Secretary General of European Society ofRegional Anaesthesia (ESRA) ( 2000 -2009)

Narinder Rawal is a professor of anaesthe-siology. His main research area is primarily inpostoperative pain and its management.Studies show that a relatively large group ofpatients have severe pain after different typesof surgery. We also know that effectivetreatments and drugs are available andtherefore there should not be a problem.Narinder has developed an organization modelon postoperative pain relief, the so-calledÖrebro model, which has received attentionboth nationally and internationally.

• “We have developed a model which allowsindividual pain management of all patientsundergoing surgery. This is a “specialistnurse-based, anaesthesiologist-supervisedmodel”. Annual audits have shown that thismodel has been working successfully fornearly 20 years” said Narinder. An importantfeature of this model is the education ofnurses on the wards, a job which is mainlycarried out by acute pain nurses.

• Thanks to advances in surgical andanaesthesiological techniques, it is becomingincreasingly common to perform daysurgery. The problem is that after majoroperations are over and when patientsreturn home, they often still suffer from pain.

• “ We are working on studies to furtherdevelop patient-controlled administration ofregional anaesthesia. This ultimately meansthat we can offer good pain relief at home.In connection with this we also developed amethod in which patients may take home asmall disposable pump filled with localanaesthetic. And when they feel pain, theycan administer the anaesthetic in the woundor near a nerve”. This is an effective method which avoids drowsiness and otherproblems of usual pain medication.

Narinder Rawal

83

Ad Rietveld MD MBARJW & Partners Ltd.

Ad Rietveld has spent most of his professionalcareer in the pricing and reimbursement ofpharmaceuticals. He is one of the few medicaldoctors whose experience in the pharmaceu-tical market encompasses clinical work, phar-maceutical industry and government. With adegree in medicine, he worked in medical prac-tice as a general practitioner in the Nether-lands and as a hospital house officer.

He gained his MBA at the Rotterdam Schoolof Management and then worked in marketingfor Solvay Duphar. Ad then worked for 11 yearsin the Dutch Ministry of Health. In his last posi-tion, he was deputy director of the Departmentfor Pharmaceutical Affairs, covering cost con-trol of medicines and medical devices and man-aging complex regulatory issues. He and his40 professional staff were responsible for thedevelopment and implementation of pharma-ceutical cost containment policies, includingthe development of a reference price systemand price controls.

Through his experience, Ad has gained a thor-ough understanding of pharmaceutical policyissues in the field of drug price reimbursement.He has a detailed knowledge of social healthcare insurance systems, and has acted as amember of international advisory and govern-mental bodies, including the European Com-mission's Pharmaceutical Pricing TransparencyCommittee. He has been closely involved withthe WHO and World Bank in the developmentof international pharmaceutical policies withemphasis on emerging EU countries. Amongothers, he has helped developing the P&R sys-tems in Vietnam, Serbia, Romania and Albania.

In August 2000, Ad Rietveld joined CambridgePharma Consultancy (now part of IMS HealthConsulting). Over the years, he has worked ona wide range of pricing and market access as-signments in numerous therapeutic areas.

Ad Rietveld

84

Prof. Lise RochaixFull Professor in the economics departmentat the university of Aix– Marseille II since 1999.Researcher at IDEP (Institut d’EconomiePublique) and GREQAM (Groupe deRecherches Quantitatives d’Aix-Marseille)Currently in secondment at the Board of HAS(Haute Autorité de Santé).

Lise Rochaix is full professor in economics witha Ph.D from York University (UK). She iscurrently in secondment at the French 'HauteAutorité de Santé' as a member of the boardand chair of the technology appraisalcommittee in charge of economic and publichealth dimensions (CEESP – Commissiond’évaluation économique et de santé publique).Before joining HAS, she had a chair at theeconomics department of the University of Aix-Marseille II where she was responsible for thepublic economics master’s degree, teachingpublic economics, labour economics and healtheconomics. She is a member of GREQAM(Groupe de Recherches en EconomieQuantitative d’Aix-Marseille) and IDEP (Institutd’Economie Publique) in Marseille. She is a member of the Board of Directors of the French economics association: AFSE - Association Française de SciencesEconomiques - and a member of the Frenchassociation of health economists: CES - Collègedes Economistes de la Santé. Her research ismainly in health economics and her areas ofinterest are related to regulatory issues, inparticular the analysis of incentives and theirimpact on both providers and patients, from anefficiency and an equity point of view. She haspublished a large number of articles on thesetopics and also taken part in variousgovernmental task force reports on healthcare reforms.

Lise Rochaix

85

Prof. Dr. Norbert SchmackeArbeits- und Koordinierungsstelle Gesund-heitsversorgungsforschung

Evidence in pain or pain in evidence?Pain management for patients with osteoarthri-tis of the knee can be considered as a perfectexample for describing systematic deficits intoday’s clinical research. The talk will start byexplaining the controversial debate about theresults of a relevant three-armed randomizedtrial that led to the reimbursement of acupunc-ture by the Germany statutory health insurancesystem for this specific pain management. Sec-ondly data will be presented about arthroscopicdebridement for osteoarthritis of the knee. Fi-nally the question is raised which study designsmight be more appropriate for developing reli-able evidence-based recommendations for agrowing public health problem like this.

Norbert Schmacke * 1948

1973 M.D. (University of Marburg)1974 Ph.D. (med.), University of

Gießen1983 Specialist in Internal Medicine1983 – 1994 Head, Department of Social

Medicine, Public Health OfficeBremen City

1986 Specialist in Social Medicine1994 – 1999 President, Academy of Public

Health, Düsseldorf1995 Postdoctoral Thesis

(Social Medicine), University of Bremen

1999 – 2003 Head, Department of Managed Care, Federal Association of the Local Health Funds (AOK), Bonn

2003- Professor of Health Sciences,Bremen University, and Head,Working and Coordinating Group ‘Health Services Research’

Norbert Schmacke

86

Ian SemmonsChairman Action on Pain, UK

After being critically injured whilst trying to pre-vent a robbery Ian has lived with chronic painfor over twenty years. As a result of his ownexperiences he formed Action on Pain in 1998which has now developed into a charity reach-ing out to people across the world. He alsoserves on the Fitness to Practice Committeesat the General Medical Council as well as beinginvolved in many health related projects overthe past fifteen years. He is married to a Char-tered Physiotherapist who has an MSc in PainManagement.

Ian Semmons

87

Dr. Alain SerrieHead of Pain Federation Palliative Medicine, France

POSITIONS AND EMPLOYMENT:1981 – 1985 Hospital Assistant – Anesthesia and Resuscitation Department1985 Hospital and University Researcher, INSERM

(National Institute for Health and Medical Research)1984 – 1998 Head of Pain Diagnosis and Treatment Department, Hôpital Lariboisière, Paris1988 Director of Clinical Training, Faculty of Medicine Lariboisière, Paris1989 – 1997 Head of Medical Activities regarding Chronic Pain Diagnosis and

Treatment - Anesthesia and Resuscitation Department, Medico-Surgical Centre1998 Head of Pain Evaluation and Treatment Capacity 1998 Head of Pain University Diploma for Health Professionals2001 Head of ‘Pain, Palliative Cares, Accompanying’ Module, Medical

Training 2nd Part of 2nd cycle, Training and Research Unit, Faculty of Medicine Lariboisière,Paris2001 – ongoing Head of Pain Federation, Hôpital Lariboisière, Paris2005 - ongoing Head of Pain Federation – Palliative Medicine,

Hôpital Lariboisière, Paris

OTHER EXPERIENCE AND PROFESSIONAL MEMBERSHIPS: 1993 - 1997 Chairman of the Francophone Society of Pain Studies

Founder Member and Chairman of the Franco-American Pain SocietyFounder Member and Vice Chairman of the Franco-German Pain Society

1997 Member of Administrative Council of Pain University Teachers National College

1997 - 2000 Member of Pain Committee of Anesthesia – French Resuscitation SocietyVice Chairman of Pain Studies and Treatment SocietyFounder Member National College of Pain Physicians

1997 - 2005 General Secretary National College of Pain PhysiciansMember of Administrative Council University College of Pain TeachersMember of Paris Hospitals Medical CollegeMember of American Pain SocietyMember of International Association for the Study of PainMember of Administrative Council of International Association“Together against Pain”Member of Administrative Council of Chronic Pain Prevention French AssociationChairman of Scientific Council of Patients’ Pain Control AssociationMember of Scientific Council “Evaluation of Triennial Government Plan of Pain Prevention”, French Public Health SocietyMember of Migraine Expertise Group, French Neurology SocietyMember of Pain Studies and Treatment SocietyMember of French Migraine and Headache SocietyMember of International Headache SocietyFormer Chairman of French Society of Pain Studies and Treatment

2001 Member of Management Council of Training and Research Unit, Faculty of Medicine Lariboisière Saint-Louis, Paris

HONORS:1985 CIBA Prize1986 Prize of 2nd International Symposium “Chronic Pain”1986 Prize MERCI of French Hospitalization, Medicine Academy1988 Prize Guy WEISWEILLER1991 Prize of Medicine National Academy

RESEARCH SUPPORT:1995 - 2009 Therapeutic trials participant (21, of which 6 as National Coordinator)

Investigation on Practices (9)Elaboration of Recommendations (11)

Alain Serrie

Dr. Antoni Sicras MainarDirectorate of Planning Badalona Serveis As-sistencialsBadalona, Barcelona (Spain)

A retrospective study to evaluate the mor-bidity profiles, the therapeutic options, andtheir cost-effectiveness in patients recei-ving regular treatment for chronic pain

Sicras, A1, Navarro, R,1 Villoria, J21 Badalona Servei Assistencials, Barcelona(Spain), 2Medixact, Madrid (Spain)

Introduction: chronic pain is gaining importanceas a major cost factor in health care.

Objectives: to identify patient morbidity groupprofiles based on treatment setting (pain unit,hospital), and complete the frequencies of pa-tients with similar morbidity profiles but differ-ent analgesic prescription. The profiles identi-fied were used in cost-effectiveness andcost-driver analyses.

Methods: a public database from local author-ities (Badalona) was selected. Data retrievedfrom patients aged over 44 who called at leastonce in any of the health care facilities withinthe study area during 2008 had a chronic con-dition (i.e. lasting more than 6 months), andwere regularly prescribed analgesics. anal-gesics. Information gathered included socio-demographic and clinical data, resource use,and comorbidities (Charlson index). Data wereclassified according to prescription of Step 1and/or 2 vs. Step 3 analgesics. Proxy meas-ures of effectiveness were used (treatment ina pain unit, treatment in a hospital, averageno. of analgesic (non-opioid) drugs per patient,

average no. of analgesic (opioid) drugs per patient, and average days spent in hospital perpatient) in the absence of direct measures. Forcost-effectiveness analysis, direct health carecosts and indirect costs associated with workdays missed because of health problems werecalculated. Patients treated in hospital or in apain unit were considered to be inadequatelytreated if they did not receive at least one Step3 analgesic. An adjusted comparison of thecosts prompted by inadequately treated pa-tients with those of the remaining sample wasmade by means of multiple linear regressions.

Results: a total of 18,157 patients met the in-clusion criteria. Only 410 (2.3%) were on Step3 analgesics. Direct health-care costs weregreater in patients on Step 3 analgesics (mean[SD]: 5,505.6 [5,046.4] �) than in patients onStep 1 and/or 2 analgesics (2,407.4 [2,436.2]�), but not indirect costs (258.5 [1,578.4] �vs. 279.5 [1,423.6] �, respectively). Using theindicators of effectiveness of in-hospital ortreatment in a pain unit, on average 2.3% and20.1% of patients were identified who were in-adequately treated with Step 1 and/or 2 anal-gesics. Regression analyses revealed greaterdirect costs in patients undertreated after ad-justing by age, gender, number of resourcesemployed and comorbidities. In opposition, in-direct costs were lower among patients inade-quately treated than in the remaining sample.

Conclusions: Step 3 analgesics are underuti-lized in this sample of patients with chronicconditions causing pain. In the absence of directmeasures of effectiveness, this research sug-gests that about 1/5 of these patients couldbe inadequately treated with Step 1 and/or 2analgesics, as they matched the profile of thosereceiving Step 3 analgesics. Step 3 analgesicswere reserved for complex situations. Patientsclassified as inadequately treated promptedgreater direct health-care costs than thoseconsidered to receive adequate treatment fortheir disease status.

88

Antoni Sicras Mainar

89

Paolo Daniele SivieroDirector of the Office for Pharmaceutical Policyat the Italian Medicines Agency (AIFA).

Department 4 Economic Strategy and Phar-maceutical policy – Office for pharmaceuticalpolicy

Therapeutic strategies for the treatment ofpain

In Italy, in recent years, have been approved aseries of rules to make easier the use of anal-gesic opiod medicines in pain therapy. A first step forward was done with the law12/2001.The main points of the law 12/2001 were:1. new prescription pad for opioid medicine in

triplice copy2. possibility to prescribe 2 opioid medicines

or 2 different dosage of the same medicinefor a therapy (maximum of 30 days)

3. home delivery of medicines included in theAnnex III bis.

The Ministerial Decree April 4 2003 intro-duces simplification and modification to law12/2001, for example prescription of activeingredients associations one of which includedin the Annex III bis and facilitation of prescriptionfor doctors.The Italian Medicine Agency (AIFA) has tried tosimplify prescription abolishing note AIFA num-ber 3 for association codeine/paracetamole,and since October 2009 it was abolished thenote AIFA number 3 and the medicine, sub-jected to note 3, were therefore reimbursedto the National Health Service without the lim-itation provided by note.Finally, it was adopted on march 2010 a newvery important law for pain therapy that intro-duce a further simplification of prescription foropioid medicines using National Service pre-scription pad, but much more important the

creation of a network for treatment of painand palliative care on a regional basis.In Italy the use of analgesic medicine for thetreatment of pain is much less than other EUcountries but there is the will to align Italy tothe rest of the world.AIFA may reassensing the possibility of elimi-nating the distinction beetween acute andchronic pain, and the class of reimbursementof such medicines.In this presentation we have analized hospitaland territorial consumption and expenditurefor opiod medicines, NSAIDs and adjuvant inrecent years.Is more difficult to estimate social impact andcost related to pain because pain is the mostcause of absenteism from work, but seemsthat treated patients costs to the society muchless than untreated patients.

Paolo D. Siviero He is also in charge of the coordination of theArea of the Italian Medicines Agencies relatedto “Economic Strategy and Pharmaceutical Pol-icy”.He has been “intellectual property and knowl-edge manager” at the Italian National ResearchCouncil (CNR).Coming from the private sector, he has beenCEO of companies in various fields. Most recent publication:P.Russo, F.S.Mennini, P.D.Siviero, G.Rasi “Annalsof Oncology” March 24 2010

Daniele Siviero

Blair H. Smith MD MEd FRCGP FHEA FRCPEdinProfessor of Primary Care Medicine; Head ofSection, General Practice and Community MedicalEducation; Deputy Head, Centre of Academic Pri-mary Care; General Practitioner, Peterhead Health Centre; Honorary Consultantin Primary Care (NHS Grampian)

Blair H. Smith is professor of primary caremedicine at the University of Aberdeen and anNHS general practitioner in Peterhead, North-East Scotland. His research in the epidemiologyof chronic pain, including neuropathic pain, hasbeen published internationally, establishing andconfirming its high prevalence and impact in thecommunity, and working towards methods of as-sessment for clinical and research purposes incommunity (primary care) based medicine. He ison the NHS Scotland Chronic Pain Steering Group,and leads its Research Subgroup. He leads theepidemiology work of the IASP NeuPSIG Committeeon Assessment of Neuropathic Pain. He is one ofthe main investigators on Generation Scotland, amajor genetic epidemiology resource aimed atidentifying genes associated with multiple healthconditions, including pain (www.generation-scotland.org). He is responsible for general practice and community medical education atthe University of Aberdeen, and also teaches research methods and medical humanities."

Research Interests: Genetic epidemiology (includingGeneration Scotland); chronic pain (including neu-ropathic pain); primary care epidemiology; medicaleducation; literature and medicine. ProgrammeDirector (Biological Mechanisms), Aberdeen PainResearch Collaboration

Teaching Interests: Clinical general practice; med-

icine in the community; research methods; epi-demiology; medical humanities; medical ethicsOther Interests: Chair, Scottish Primary Care Re-search Network, Northern Node; Generation Scot-land, Executive Committee Member; Chair, NHSScotland Chronic Pain Steering Group (ResearchSub-group); Research Governance; Regular columnin "Hoolet" and in other writing.

Five recent publications:Smith BH, Campbell H, Blackwood D, Connell J,Connor J, Deary I, Dominiczak A, Fitzpatrick B,Ford I, Jackson C, Haddow G, Kerr S, Lindsay RS,McGilchrist M, Morton R, Murray G, Palmer C,Pell JP, Porteous D, Ralston SH, St. Clair D,Sullivan FM, Watt GCM, Wolf R, Wright A, MorrisAD. Generation Scotland: the Scottish FamilyHealth Study; a new resource for researchinggenes and heritability. BMC Medical Genetics2006 7 74.

Smith BH, Torrance N, Bennett M, Lee AJ. Healthand quality of life associated with chronic pain ofpredominantly neuropathic origin in the community.Clinical Journal of Pain 2007 23 143 – 149

Smith BH, Macfarlane GJ, Torrance N. Epidemi-ology of chronic pain, from the laboratory to thebus stop: time to add understanding of biologicalmechanisms to the study of risk factors in popu-lation-based research? Pain 2007 127 5 – 10.

Haanpää M, Backonja M-M, Bennett M, BouhassiraD, Cruccu G, Hansson P, Jensen TS, Kauppila T,Rice A, Smith BH, Treede R-D, Baron R. Assess-ment of neuropathic pain in primary care. Amer-ican Journal of Medicine 2009 122 S13 – S31

Torrance, N, Elliott AM, Lee AJ, Smith BH. Severechronic pain is associated with increased 10 yearmortality. A Cohort record linkage study. EuropeanJournal of Pain 2010 14 380 – 386

Hocking L, Smith BH, Jones GT, Reid DM, StrachanDP, Macfarlane GJ. Genetic variation in the beta2-adrenergic receptor but not catecholamine-O-methyltransferase predisposes to chronic pain.Pain 2010 149 143 - 151

Outside Interests: Three children; Music – singing,piano, church organ, guitar, clarinet; Poetry -reading and writing; Running; Elder, MethlickChurch of Scotland

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Blair Smith

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Dr. med. Reinhard ThomaAnaesthesiologist/ Pain SpecialistAlgesiologikum MVZPain Medicine CenterMunich

Why do we need an ICD-10 code for chronicpain?

Pain is one of the most frequent reasons tovisit health professionals. The prevalence rateof chronic pain in Germany is reported to be17 %. The relative risk of suffering from chronicpain during a lifetime is supposed to be morethan 0.80. If pain persists longer than 6months, it tends to result in psycho-social im-pairment, increased disability, reduction of qual-ity of life and increased health care costs.

The International Classification of Diseases (ICD10) classifies pain primarily in the different sec-tions of the organic diseases as the origin ofpain, i.e. low back pain or slipped disc. Oftenthe cause of pain conditions remains unclear.There is evidence that cognitive, affective andbehavioural factors play a central role in in-creasing and maintaining pain symptoms.Therefore many patients need additional psy-chiatric or psychological interventions such ascognitive–behavioural therapy. In chronic painconditions, multidisciplinary and multimodal con-cepts of pain therapy have the best scientificevidence.

These therapeutic approaches require a lot ofmedical care resources, particularly with re-gard to staff requirements. With the imple-mentation of DRG systems (diagnoses relatedgroups) as the basis of reimbursement of hos-pital treatment in Germany, the ICD 10 classi-fication system became more important: Whatwe cannot code does not exist in the reim-bursement system. The bio-psycho-social di-mensions of chronic pain need a multidimen-sional approach to the problem. Monocausalbiomedical causality is as unfeasable as mono-causal psychological conditions.

The ICD 10 (German modification) establishedin 2009 the new Code F45.41 (“Chronic paindisorders with somatic and psychological fac-tors“) that allows the coding of chronic painconditions requiring psychologic or psychiatricintervention. In Germany, this new ICD 10 Code serves as a marker in morbidity-oriented compensation systems like the diagnosis-related groups (DRG) or the morbidity-oriented risk adjustment fund.

Reinhard Thoma

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Wil ToendersFormer secretary of Dutch Medicines Reim-bursement Advice Committee, now independ-ent consultant in healthcare and medicines re-imbursement issues.

Education: graduated as a pharmacist with asubsidiary in general practice.

Work experience: after practising in a phar-macy in a healthcare centre in Amsterdam,he became editor of the Dutch Drug Bulletin in1990 and was General Secretary of the Inter-national Society of Drug Bulletins from 1996.In 1999 he joined the Dutch Healthcare Insur-ance Board as a pharmaceutical adviser. From2004 to 2009 he was secretary of the DutchMedicines Reimbursement Advice Committee,the independent expert committee responsiblefor advising the Ministry of Health on the reim-bursement of medicines.

Present role: on 1st January 2009 he startedhis own independent consultancy companyToendersdeGroot, which advises on healthcareand medicines reimbursement issues. Amongthe activities are: participation in scientific ad-visory boards, advising on strategic issues, ad-vising on the design of clinical trials, doing re-imbursement feasibility studies and preparingreimbursement dossiers.

Wil Toenders

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Prof. Dr. med. Dr. med. habil. Dr. rer.nat.Thomas R. Tölle is a neurologist and psycholo-gist.

Outcome measures in back pain: objectivemeasurement of motor performance of theback with a spine sensor

Thomas R. Tölle (1) and Dirk David Goldbeck (2)1 Dept. of Neurology, Technische UniversitätMünchen; 2 OsteoDynamiX GmbH, München

A main target in the treatment of low back pain is the reduction of pain. However, forpayers and reimbursement authorities therestoration of functionality and productivity is alikewise important outcome. Clinical trials onback pain use a variety of psychometric tests,including patients satisfaction and quality-of-lifeparameters, and back pain related tools suchas Oswestry- or Roland-Morris-Disabilityquestionnaires to depict the status and theoverall improvement of the patient. In respectto function and motor performance, the clinical orthopedic/neurological examination isstandard. Functional tests in physiotherapy,strength tests or work-related performanceare occasionally utilized to gather moredetailed information on the functional capacityof the patient. If it comes to the currentlyavailable outcome measures in back pain, wehave to face an unquestionable mismatchbetween the measurement of subjectiveexperience of pain and well-being with objectivemotor performance of back function. This canweaken the overall appraisal of any pharma-co-, physio- or cognitive therapy intended toimprove “pain and function” in this group ofpatients.

Although the satisfaction of a patient is animportant subjective yardstick, a next targetshould be the establishment of a moreobjective measure of function. This can beachieved by developing a specific technologythat measures real improvement of function,e.g. with respect to a pre-specified set ofexercises. Preferably, this tool measuresvelocity and mobility with high resolution ofspace and time. We are now able to report a new system(Spine Sensor from OsteoDynamiX GmbH, aspin-off of Siemens AG) for in-vivo real-timeassessment of motor performance in lowback pain. The system is able to continuouslyrecord motion in the lumbar part of thevertebral column regarding flexion, extensionand rotation, and store the generated datawith a high sampling rate (50 Hz) making itpossible to evaluate a broad range of basalmotion. Measurement of function wasascertained from the dynamics of motion inrecordings of day-to-day life and from asupervised motion choreography allowing forseveral post-analysis steps. Our pilot studyresults have methodological and substantialimplications for the study of back pain. Wecould demonstrate high reliability of short-term and long-term measurements that is superior to the modest reliability of existingmeasurements in this area. Hence, a new assessment of the efficiency oftherapeutic procedures in the future using thisOsteoDynamiX Spine Sensor system is likely tobe of immediate use not only for patients, butalso for cost units. New developments indiagnostics and therapy monitoring arecurrently emerging with application of the toolin healthy controls and back pain patients. .

Thomas R. Tölle

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Prof. Dr. med. Rolf-Detlef TreedePresident Deutsche Gesellschaft zum Studium desSchmerzes e.V. (German Pain Society)

Lehrstuhl für Neurophysiologie - Zentrum fürBiomedizin und Medizintechnik Mannheim Medizinische Fakultät Mannheim der UniversitätHeidelberg Ludolf-Krehl-Str.13-17 D-68167 Mannheim Germany

Professor Treede is a past member of the Council ofthe International Association for the Study of Pain(IASP), Chair of its Special Interest Group onNeuropathic Pain (NeuPSIG), and President of itsGerman chapter (Deutsche Gesellschaft zum Studiumdes Schmerzes e.V., DGSS). He sits on numerousnational and international committees, is involved witha number of task forces – including the IASP TaskForce on Taxonomy – and is a member of the editorialboards of the journals, Pain and Der Schmerz. He hasauthored/co-authored about 200 publications injournals and books.

Theses on the Ethics of Pain Therapy 1) Freedom from pain is an essential element of

human well-being. 2) Pain therapy is a fundamental human right. 3) Everyone has the same right to adequate pain

relief. 4) Everyone has the right to die without suffering

from pain, if necessary even with the risk ofadverse effects

5) Pain relief should respect the patient's autonomy 6) Pain therapy must not cause harm. Early death in

cancer patients as a result of pain therapy is notto be considered as harm.

7) Pain relief must not hinder self-determination. 8) Risks of pain therapy may only restrict thera-peutic

measures, if the resulting advantages of paintherapy are reduced.

9) Chronic pain is to be prevented by effectivelytreating acute pain.

DGSS Ethics Charter - Synopsis The DGSS Ethics Charter is a document offeringethical orientation in fundamental questions and

special challenges in dealing with pain. It is intendedfor all those treating pain, accompanying thosesuffering from pain or those who are themselvesaffected by pain. The complete Ethics Charter in German and a shortversion in English are available free of charge from:

Geschäftsstelle der DGSSObere Rheingasse 356154 BoppardTel: +49 6742 8001-21Fax: +49 6742 8001-22E-Mail [email protected] http://www.dgss.org

Coding chronic pain in the InternationalClassification of Diseases (ICD 10)ICD 10 was endorsed by the Forty-third World HealthAssembly in May 1990 and came into use in WHOMember States as from 1994. The classification isthe latest in a series which has its origins in the1850s. Not surprisingly, ICD 10 fares better inrepresenting medical subspecialties (psychiatry in theF section, orthopaedic surgery in the M section,neurology in the G section) than interdisciplinaryproblems such as chronic pain. In 2009, the German version of ICD-10 introduced thediagnosis of “Chronic pain disorder with somatic andpsychological factors” (F45.41) to better reflect thebiopsychosocial character of chronic pain. Adichotomous classification into psychologically causedpain (e.g. F62.8 or F45.4) versus biomedically causedpain (e.g. M54) is inappropriate, because the majorityof patients have elements of both etiologies, as shownmost clearly for low-back pain. The new code F45.41addresses the relevance of psychological factors forchronic pain persistence and chronic pain treatment,even in those conditions with a clear biomedical causeat the beginning. This new code may be a model forworldwide implementation in the upcoming ICD11. Using such a code systematically is expected to havethese practical consequences:

1) Patients with chronic pain, where pain has lost itswarning function, receive a medically recognizeddiagnosis.

2) A pain state with such a label will help recognitionas a “legitimate” medical problem.

3) Health care costs for difficult-to-treat cases aredistinguished from those for uncomplicated cases.

4) Once the health care costs for chronic pain are delineated, the motivation to includeinterdisciplinary differential diagnosis and therapyof pain into medical school curricula may increase.The first data on the use of F45.41 in Germany areexpected to be available in summer 2010.

Nilges P, Rief W (2010) F45.41 ChronischeSchmerzstörung mit somatischen und psychischenFaktoren – eine Kodierhilfe. Der Schmerz 24 (2): inpress

Rolf-Detlef Treede

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Dr. Martin van der GraaffSecretary of the Medicinal Products Reim-bursement CommitteeDutch Healtcare Insurance Board (CVZ).

Martin van der Graaff (1955) studied Phar-macy and received his Ph.D. at Leiden Univer-sity. He spent 11 years in R&D at Organon andSolvay Pharma, covering subjects such aslyophilization, injection formulation, human phar-macokinetics and bioequivalence, preclinical de-velopment studies, and toxicology. He thenmoved on to the association of the innovativepharmaceutical industry, Nefarma. For 12years he was, in different positions, responsiblefor subjects ranging from regulatory and reg-istration issues, biotechnology, environmentalissues, to orphan drugs and sustainable devel-opment. In 2008 he changed track from theprivate to the public sector and joined theDutch Healthcare Insurance Board, and hasbeen Secretary of the Medicinal Products Re-imbursement Committee (CFH) since Jan 1,2009.

Painlessly into the package: incorporating paintreatment innovations

The cost of medicinal product seems to berelatively modest as compared to the overallcost of combating pain. There is however, agreat number of pain treatments around thatmay add significantly to overall investment ofhealthcare money.

Reviewing innovations in the treatment of painwill increasingly become a challenge. Thefinancial crisis may indirectly lead to higherthresholds.

Remarkably, companies still have difficulty indesigning their studies in such a way that thedata facilitate decision making forreimbursement. This holds not only formedicinal products, but also for operationtechniques and devices. Several steps might betaken to alleviate the problem, e.g. advances inclinical trial design. But at the same time,dialogue should be fostered betweencompanies, patients, the medical professionand reimbursement authorities in order todefine a shared framework of reference.

What would constitute innovations that areworth paying for from healthcare funds? Canwe define benchmarks for the extent ofimprovement that can be expressed in digitsand Euros? This would help to either improvestudy design or to abandon attempts in provingthe impossible. Conversely, a parallel dialogueshould be started with the aim of deletingobsolete or unproven techniques, devices andmedicinal products from the reimbursementsystem.

An innovation agenda shared by bothreimbursement authorities and otherstakeholders cannot be made binding on theparties concerned, but may provide a veryuseful yardstick to measure new approachesagainst their competitors and existingmethods. The role of the Dutch HealthcareEvaluation Board (CVZ) and possible conditionalreimbursement schemes is briefly discussed.

Martin van der Graaff

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Michel VanhalewynGeneral CoördinatorSociété scientifique de Médecine générale(SSMG)

Pain management in practiceRecently, via a better awareness of the medicalprofession associated with development ofneuroscience, the domain of pain knew obviousprogress. These advances in science led to takinggreater account of the person who is sufferingfrom pain, with a better understanding of thedifferent factors and possible treatments.They will also influence the future of the patientand the evolution of its painful phenomenon.Progress will become a priority in public healthin view of the evolution of life and the conceptof global health (physical, mental and social).The approach is fundamentally different foracute and chronic pain.The treatment of acute pain is often etiologicaland drug therapy is often better to treat thesymptom. The action of different medicationscan be effective at different levels: blocking ordecrease sensitivity receptors (prostaglandinsynthesis inhibitors), changing neurotrans-mission (tricyclic antidepressants), and acti-vating opioid receptors at the central nervoussystem (morphine and derivates).Clinical studies on the treatment of chronicpain are facing many difficulties. Most aremade in the framework of postoperative painor concerns only a period short (4-8 weeks). When the pain becomes chronic, the sameapproach can remain relevant. On the otherhand, if pain is part of a chronic pain syndrome,isolated drug approach must be questioned.There is a large individual variability ofresponses to the painkillers. Chronic pain isassociated with a significant regression

relational and functional capacity, an excessiveuse of medicines and medical procedures, anda mood disorder. The medical approachrequest a change in the attitude of caregiversproviding coaching patients more adapted andaccompanied by nature social and psycho-logical interventions. The functional rehabilitation has an importantplace in the therapeutic process. The beneficialshort-term and long-term multimodal cognitive-behavioural treatment effect was reported inmany international studies.

Michel Vanhalewyn

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Prof. Giustino VarrassiPresident EFICDirector at the Department of AnaesthesiologyPost-Grad, University of L’Aquila, Medical SchoolDirector at the Department of Anaesthesiology,University of L’Aquila, Medical SchoolProfessor and Chairman of Anaesthesiology,Intensive Care and Pain Centre Department atASL 04 of L’AquilaPresident of Clinics Council

Pain is certainly one of the most disturbing dis-eases affecting mankind at all ages. It is ex-tremely frequent after 65 years of age, whenits prevalence is around 50%. Many of theHealth Care Systems (HCS) around the world,especially in highly industrialized countries, areoverwhelmed by the high incidence of costsdue to chronic pain.

At the moment, awareness is increasing moreand more and more that chronic pain repre-sents a social burden. It would be enough toobserve the data from the literature relatedto the extremely high incidence of low-backpain, a very invalidating disease, especially whenpeople are still expected to have a normal work-ing life. It is also interesting to observe that pa-tients with chronic pain lose working days justbecause of pain.

Notwithstanding all this, the totality of the HCSdoes not recognize pain with the dignity itshould deserve, as a disease in its own right.Because of this, almost all the syndromes withpain are not adequately represented in medicaldocumentation systems like diagnosis-relatedgroups (DRG). Hence, often pain is not ade-quately represented in the reimbursement sys-tem. This is certainly one of the most importantreasons why chronic pain, by many stakehold-ers involved, is regarded as a social burden.

Besides that, and especially after the promul-gation of a very advanced law in Italy, recogniz-ing for all the citizens the right to be cured fortheir pain by the national HCS for free, paincare seems to be a valid top indicator for thequality of the HCS.

With this in mind, EFIC has decided to organizea scientific symposium where policy makers,administrators and payers of the health sys-tems may freely and fruitfully discuss such animportant issue. The symposium is structuredin order to give every participant some initialcommon scientific insight to work on. After theinitial part, participants are invited to take partin one of the workshops, where they can con-tribute with their personal know-ledge and work-ing experiences. At the end of the workshopsthe results will be summarized and reportedby one of the members to the rest of the par-ticipants.

EFIC is very much convinced of the enormousimportance of this topic. This is why the "Soci-etal Impact of Pain" will also be the topic of the2010 European Week Against Pain (EWAP),the traditional annual awareness campaignthat EFIC has organized every year since 1999.

Giustino Varrassi

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Dr. rer. pol. Dipl.-Ök. Christoph VauthHead of Integrated Heath-Care, KKH-Allianz

PROFESSIONEL EXPERIENCE & EDUCATIONSince 10/2009 Head of Integrated Health-Care

KKH-Allianz (statutory Health Insurance Funds)

05/2009 - 09/2009 Head of Research / Managing DirectorCentre for Health EconomicsLeibniz University Hannover

05/2009 Doctoral thesis:„Secondary research in Health Economics: The example of the assessment of strong opioids in chronical pain therapy“Degree: Doktor der Wirtschaftswissenschaften (Dr. rer. pol.)

01/2007 – 05/2009 Head of the Health-Technology-Unit, Centre for Health Economics

01/2003 – 05/2009 Research FellowCentre for Health Economics Leibniz University Hannover

10/1998 – 12/2002 Studies in Economics (Leibniz University Hannover)Diploma thesis:Diagnosis Related Groups – Introduction and impactto the German healthcare systemDegree: Diplom-Ökonom

08/1996 – 12/1998 Apprenticeship as a bank employeeSavings Bank Schaumburg-Lippe

AKADEMICAL TEACHING ACTIVITIES

SS (Summer-Semester) 2009 Lecture ‚Business Economics in healthcare markets’,Leibniz University Hannover

WS (Winter) 2006 - WS 2008 Lecture ‚Health Insurance and Health Economics I ‘, Leibniz University Hannover

WS 2003 – WS 2005 Lecture ‚Introduction in Business Economics‘,Leibniz University Hannover

SS 2003 – SS 2006 Examiner for ‚Applied Health Economics‘University of Bielefeld

Since SS 2003 Visiting lecture ‚Business Economics in healthcare markets’ (2003- 2006) and examiner for bachelor thesis (today)University of Applied Science Magdeburg-Stendal

Since SS 2004 Visiting lecture ‚Health Economic Evaluations’Universitätsklinikum Berlin, Campus Charité (Institut für Klinische Pharmakologie und Toxikologie)

SS 2005 – SS 2007 Visiting lecture ‚Health Economics‘University of Lüneburg

Since SS 2006 Visiting lecture ‚Competition at the health care market’National Association of Statutory Health Insurance Physicians (KBV), Berlin

Christoph Vauth

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Renata Villoro PhD PhD in Public Policy. Degree in Economics. Mas-ter in Health EconomicsInstituto Max Weber

The social costs of chronic pain in Spain

Studies on chronic pain and its social costsare scarce in Europe and particularly in Spain.A recent European survey reveals that the per-centage of the Spanish population sufferingfrom moderate and severe chronic pain is 5and 6 percent, respectively. Using the most re-cent available data on chronic pain in Spain,and following different costing methodologies,we assess the total social costs of chronic painin Spain. We emphasise on indirect and intan-gible costs, including home care, labour dayslost to temporary and permanent incapacity,and costs attributable to quality of life loss. Weestimate that in 2005 the costs associatedwith labour days lost to chronic pain and infor-mal home care could have added up to 13,400million Euros, which is approximately 1.5% ofthe Spanish GDP. This figure does not includeexpenditure in health care services nor intan-gible costs. Given the importance of accuracyin this field of knowledge, we highlight the ur-gent need for well designed representative sur-veys and further studies on chronic pain andits related costs in Spain and Europe.

Authors:Julio López Bastida. Servicio de Evaluación.Servicio Canario de Salud. CIBER Epidemi-ología y Salud Pública (CIBERESP)Juan Oliva. Universidad de Castilla La Man-cha. CIBER Epidemiología y Salud Pública(CIBERESP)Alvaro Hidalgo. Universidad de Castilla-LaMancha and Instituto Max WeberRenata Villoro. Instituto Max Weber

Renata Villoro

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Prof. Paul J. Watson FCSPProfessor of Pain Management and Rehabilitation Department of Health Sciences, Academic Unit University of Leicester, UK

The costs of musculoskeletal pain: the needfor priority services.Musculoskeletal pain is a ubiquitous conditionmost people will experience at sometime intheir lives. This commonality and the expecta-tion that it is simple part of life may have ledto few taking it seriously enough to make themanagement of musculoskeletal pain a prior-ity in comparison with other conditions. Musculoskeletal conditions remain one of thecommonest reasons for a primary care con-sultation. Persistent pain may affect as muchas 50% of older people rising to over 80% inthose resident in nursing homes. With an ag-ing population in all European countries thenumber with persistent pain is likely to in-crease.Direct treatment costs (health care) of lowback pain in the UK alone in 1998 including so-cietal and health care costs was £12 billion.This is greater than the total costs associatedwith other chronic health conditions such ascoronary heart disease and diabetes at thattime. Both CHD and diabetes have a NationalService Framework for treatment, in part be-cause of the perception of the size and cost of

the conditions. It has been estimated that thedirect costs of musculoskeletal pain, includinginflammatory arthritis, accounts for 2% of theGross Domestic Product of Europe.Recent figures on work loss found that afterseasonal coughs and colds, musculoskeletalconditions were the foremost reason for short-term work absence in manual workers and thesecond most common reason for long-termabsences. In non-manual workers it was thesecond most common reason for short-termabsence and the fourth most common reasonfor long-term absence. When employees wereasked about conditions they had in the previous12 months 43% of people with a health condi-tion reported a musculoskeletal pain conditionwhich on average resulted in 16.4 days offwork.Persistent pain is a public health issue; the 10year mortality rates are much higher in chronicpain patients and suicide rates are double therest of the population. They experience in-creased incidences of mental illness and sub-stance abuse and persistent pain has an ad-verse effect on daily activity, mood, sleep,general health and even income. There are effective treatments to help managemusculoskeletal pain but it remains under-recognised and undertreated. Local initiativesin some countries in the EU are endeavouringto implement evidence-based approaches butthese require a political will to ensure they aresuccessful which should be delivered throughmaking the management of pain an overt na-tional priority.

Paul J. Watson

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Dr. Eva Zebedin-Brandl PhD Department of Pharmaceutical AffairsMain Association of Austrian Social SecurityInstitutions

Pharmaco-economical aspects on the costof pain

Eva Zebedin-Brandl and Thomas Burkhardt

Pharmaceutical expenditure continued to risesteadily in Austria during the 1990s and early2000s despite a variety of reforms. As re-viewed in Godman et al (2008), recent reformsand initiatives have moderated the growth rate.Overall, health care in Austria seems well es-tablished, and a total of 98% of Austrians arecovered by social (statutory) health insurance.However, providing modern and comprehensivemedical care is inevitably and causally linked toa constant rise in health care costs. This risingfinancial burden is a common concern, copingstrategies vary among different Europeanstates due to differences in health care struc-tures and administrative impact. In Austria, theHVB (Main Association of Austrian Social Se-curity Institutions) publishes the Reimburse-ment Code (EKO) for outpatient medicines, andif new medicines apply for inclusion they aresubjected to pharmacological, medical/thera-peutic and health economic evaluation. Treatment of pain has a unique position in eachhealth care system. Pain patients are con-fronted both with severe and disabling physicalas well as psychological burdens. Good medicalcare is the only way to avoid social marginal-ization. Very often pain perception includes psy-chosomatic and mental aspects. In this studywe basically distinguish between two maintreatment groups as representatives for pain

medication: classical NOAs (non-opioid anal-gesics) and opioids. We aim to investigate theimpact of social factors on prescribing habitsand/or patients’ pain medication in these twogroups. First we are interested if there aregross differences in the of the age distributionbetween the two groups in Austria. Next weare interested in the impact of recent socialreforms. This can easily be followed over timeand we hope to learn if and how greater avail-ability or the restriction of pain medication (e.g.due to the introduction of generics) or the waiv-ing of prescription fees influence the rate ofutilization of pain medication. Another interest-ing social aspect is the seasonal influence onpain medication. We intend to analyze themonthly fluctuations in utilization and try toidentify seasonal factors, e.g. use of antipyreticsfor upper respiratory tract infections vs. opioidsfor more severe pain. Data were provided bythe internal data warehouse of the HVB, whichhouses reimbursement data for ambulatorycare from 2001-2009.

Eva Zebedin-Brandl

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This symposium is organized by EFIC® and generously sponsored byGrünenthal GmbH

www.EFIC.org

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