Niels K. Rasmussen

Critical issues on opioids in chronic non-cancer pain: An epidemiological study

&NA; The aim of the study was epidemiologically to evaluate the long‐term effects of opioids on pain relief, quality of life and functional capacity in long‐term/chronic non‐cancer pain. The study was based on data from the 2000 Danish Health and Morbidity Survey. As part of a representative National random sample of 16,684 individuals (>16 years of age), 10,066 took part in an interview and completed a self‐administered questionnaire. Cancer patients were excluded. The interview and the self‐administered questionnaire included questions on chronic/long‐lasting pain (>6 months), health‐related quality of life (SF‐36), use of the health care system, functional capabilities, satisfaction with medical pain treatment and regular or continuous use of medications. Participants reporting pain were divided into opioid and non‐opioid users. The analyses were adjusted for age, gender, concomitant use of anxiolytics and antidepressants and pain intensity. Pain relief, quality of life and functional capacity among opioid users were compared with non‐opioid users. Opioid usage was significantly associated with reporting of moderate/severe or very severe pain, poor self‐rated health, not being engaged in employment, higher use of the health care system, and a negative influence on quality of life as registered in all items in SF‐36. Because of the cross‐sectional nature causative relationships cannot be ascertained. However, it is remarkable that opioid treatment of long‐term/chronic non‐cancer pain does not seem to fulfil any of the key outcome opioid treatment goals: pain relief, improved quality of life and improved functional capacity.

Trends in smoking behaviour between 1985 and 2000 in nine European countries by education

Objective: To examine whether trends in smoking behaviour in Western Europe between 1985 and 2000 differed by education group. Design: Data of smoking behaviour and education level were obtained from national cross sectional surveys conducted between 1985 and 2000 (a period characterised by intense tobacco control policies) and analysed for countries combined and each country separately. Annual trends in smoking prevalence and the quantity of cigarettes consumed by smokers were summarised for each education level. Education inequalities in smoking were examined at four time points. Setting: Data were obtained from nine European countries: Norway, Sweden, Denmark, Finland, the United Kingdom, the Netherlands, Germany, Italy, and Spain. Participants: 451 386 non-institutionalised men and women 25–79 years old. Main outcome measures: Smoking status, daily quantity of cigarettes consumed by smokers. Results: Combined country analyses showed greater declines in smoking and tobacco consumption among tertiary educated men and women compared with their less educated counterparts. In country specific analyses, elementary educated British men and women, and elementary educated Italian men showed greater declines in smoking than their more educated counterparts. Among Swedish, Finnish, Danish, German, Italian, and Spanish women, greater declines were seen among more educated groups. Conclusions: Widening education inequalities in smoking related diseases may be seen in several European countries in the future. More insight into effective strategies specifically targeting the smoking behaviour of low educated groups may be gained from examining the tobacco control policies of the UK and Italy over this period.

Epidemiology of chronic non-malignant pain in Denmark.

&NA; A series of health surveys are conducted every sixth to seventh year in Denmark. In the most recent survey of 2000, a national random sample (>16 years) was drawn from the Danish Central Personal Register. Out of the original sample 12,333 (74%) were interviewed and of these 10,066 returned a completed questionnaire (SF‐36). The present study includes only those who both took part in the interview and the postal questionnaire. Cancer patients were excluded. Persons suffering from chronic pain (PG) were identified through the question ‘Do you have chronic/long lasting pain lasting 6 months or more’? An overall chronic pain prevalence of 19% was found −16% for men and 21% for women. Prevalence of chronic pain increased with increasing age. Persons ≥67 years had 3.9 higher odds of suffering from chronic pain than persons in the age group 16–24 years. Compared with married persons, divorced or separated persons had 1.5 higher odds of chronic pain. Odds for chronic pain were 1.9 higher among those with an education of less than 10 years compared with individuals with an education of 13 years or more. During a 14‐day period reporters of chronic pain had an average of 0.8 days (range 0–10) lost due to illness compared with an average of 0.4 days (range 0–10) for the control group (CG) (Odds Ratio (OR)) 2.0). Persons with a job which required high physical strain were more likely to report chronic pain compared with those with a sedentary job (OR 2.2). The odds of quitting ones job because of ill health were seven times higher among people belonging to the PG. A strong association between chronic pain and poor self‐rated health was also demonstrated. The PG had twice as many contacts with various health professionals compared with the CG, and the health care system was, on average, utilised 25% more (overall contacts) by the PG than by the general population. Among the persons in the PG, 33% were not satisfied with the examinations carried out in connection with their pain condition and 40% were not satisfied with the treatment offered. Nearly 130,000 adults, corresponding to 3% of the Danish population, use opioids on a regular basis. Opioids are used by 12% of the PG.

Differences in self reported morbidity by educational level: a comparison of 11 western European countries.

STUDY OBJECTIVE: To assess whether there are variations between 11 Western European countries with respect to the size of differences in self reported morbidity between people with high and low educational levels. DESIGN AND METHODS: National representative data on morbidity by educational level were obtained from health interview surveys, level of living surveys or other similar surveys carried out between 1985 and 1993. Four morbidity indicators were included and a considerable effort was made to maximise the comparability of these indicators. A standardised scheme of educational levels was applied to each survey. The study included men and women aged 25 to 69 years. The size of morbidity differences was measured by means of the regression based Relative Index of Inequality. MAIN RESULTS: The size of inequalities in health was found to vary between countries. In general, there was a tendency for inequalities to be relatively large in Sweden, Norway, and Denmark and to be relatively small in Spain, Switzerland, and West Germany. Intermediate positions were observed for Finland, Great Britain, France, and Italy. The position of the Netherlands strongly varied according to sex: relatively large inequalities were found for men whereas relatively small inequalities were found for women. The relative position of some countries, for example, West Germany, varied according to the morbidity indicator. CONCLUSIONS: Because of a number of unresolved problems with the precision and the international comparability of the data, the margins of uncertainty for the inequality estimates are somewhat wide. However, these problems are unlikely to explain the overall pattern. It is remarkable that health inequalities are not necessarily smaller in countries with more egalitarian policies such as the Netherlands and the Scandinavian countries. Possible explanations are discussed.

Chronic pain and other sequelae in long‐term breast cancer survivors: Nationwide survey in Denmark

Objectives: To investigate self‐reported chronic pain and other sequelae in a nationally representative sample of long‐term breast cancer survivors (BCS).

Social position and health in old age: the relevance of different indicators of social position

Aims: An analysis was undertaken to investigate social inequalities in health among old men and women in relation to five indicators of social position. Methods: The study is based on a population-based cross-sectional survey among 748 75-year-old men and women, which was performed as clinical examinations and interviews in 1989 in Glostrup, a suburban area west of Copenhagen. Social position was measured by vocational education, occupation, social class, income, and housing tenure. Health was measured by number of chronic diseases, tiredness in relation to mobility, need of help in relation to mobility, oral health (number of teeth), and well-being (the CES-D Scale). The statistical analysis included bivariate contingency tables and logistic regression analyses. Results: Two material wealth variables (income and tenure) were consistently related to nearly all health measures while the relationships between the other social position variables and health showed no consistent patterns. Multiple logistic regression analyses with tenure and income as independent variables and each of the health variables as dependent variables and control for education and occupation showed different patterns for men and women. In men the odds ratios of housing tenure on four health variables were strong and unaffected by education and occupation while in women the odds ratios of income on three health variables were strong and unaffected by education and occupation. Conclusion: This study demonstrates strong, consistent associations between variables of material wealth indicators and various measures of health among 75-year-old men and women.

Development of and recovery from long-term pain. A 6-year follow-up study of a cross-section of the adult Danish population

&NA; A 6‐year follow‐up study of a cross‐section of the adult Danish population, based on data from the Danish Health and Morbidity Surveys in 1994 and 2000 is presented. The pain populations were identified through the pain intensity verbal rating scale (VRS) included in the Short Form 36. The 2000 survey also included a question on duration of pain (>6 months). Using this as the ‘gold standard’, a validation study was performed, which identified the highest accuracy (85%) at the VRS cut‐off level: no pain, very mild, or mild pain (control group) versus moderate, severe, or very severe pain (pain group). The cohort comprised 2649 individuals, representative of the Danish population. Prevalence rates of pain in 1994 and 2000 were 13.5 and 15.7%, respectively. The cumulated 6‐year incidence of pain development was 10.7%, and the cumulated incidence of pain recovery was 52.1%. During the investigated period, 9.2% of individuals moved from a ‘no pain status’ to a ‘pain status’, 7% moved from a ‘pain status’ to a ‘no pain status’, and 6.5% maintained their ‘pain status’. Significant risk factors for pain development were female gender [odds ratio (OR) 1.5, 95% confidence interval (CI) 1.2–2.0], short education (OR 1.5, CI 1.0–2.2), poor self‐rated health (OR 3.3, CI 2.4–4.7), and having at least one long‐standing disease (OR 2.6, CI 2.0–3.4). Significant predictors for pain recovery were male gender, younger age, cohabitation status, good self‐rated health, good mental health, having no long‐standing disease, and having an annual income above US

Health care utilisation among individuals reporting long-term pain: an epidemiological study based on Danish National Health Surveys

15 400.

The validity of self-reported fractures among Danish female nurses: comparison with fractures registered in the Danish National Hospital Register

Individuals reporting long‐term pain in the 1994 and 2000 Danish Health and Morbidity Surveys, which included random samples of 6000 and 16,684 persons respectively, were investigated concerning their use of the health care systems. A considerably higher use was observed in the pain population in the primary as well as the secondary health care sector, compared with a no pain control group. In 1994, individuals reporting long‐term pain had on average 12.8 contacts per year to the primary health care sector compared with 7.3 for the control group. Use of secondary health care sector as estimated by hospital admission frequency and number of in‐hospital days was not only significantly higher for the pain group but showed also an increasing tendency during the periods investigated (1991–1997). Women used the health care system significantly more than men, whereas age did not seem to influence.

The effect of health, socio-economic position, and mode of data collection on non-response in health interview surveys

Background: The authors compared self-reported non-spine fractures obtained from a cohort of Danish female nurses with fracture diagnoses registered in the Danish National Hospital Register (DNHR). Method: The self-reported fracture history was obtained from a questionnaire and was related to fracture information registered with the DNHR by means of the unique person identification code of Danish citizens. A total of 166 self-reported hip fractures, 391 self-reported wrist fractures, and 121 self-reported upper arm fractures were available for the comparison. The self-reported fractures were initially compared with the anatomic specific fracture diagnoses registered in the DNHR. Second, the comparison also included fracture diagnoses of adjacent skeletal sites (unspecific fracture diagnoses). Results: The positive predictive value of a positive report of hip fracture was 89%. Inclusion of unspecific registered hip fractures increased the positive predictive value to 94%. The same figures for wrist fractures were 75% and 84%, respectively, and for upper arm fractures 54% and 83%, respectively. The predictive value of a negative report of hip fracture was 99.5%. The fracture year was correctly reported in 76% of the hip fracture cases, 81% of the wrist fracture cases, and 82% of the upper arm fracture cases. Predictors of false-positive report of fractures were young age (<60 years), report of indoor falls in the previous year, and use of hormone replacement therapy (HRT). Conclusion: The authors conclude that self-report of hip, wrist, or upper arm fractures among Danish nurses is relatively accurate but varies by the site of fracture. False positive reports of fracture introduce only modest bias fracture risk estimates and tend to dilute the association between exposures and fracture.