Ola Ekholm

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.

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.

Health promoting outdoor environments - Associations between green space, and health, health-related quality of life and stress based on a Danish national representative survey

Aims: To investigate the associations between green space and health, health-related quality of life and stress, respectively. Methods: Data were derived from the 2005 Danish Health Interview Survey and are based on a region-stratified random sample of 21,832 adults. Data were collected via face-to-face interviews followed by a self-administered questionnaire, including the SF-36, which measures eight dimensions of health and the Perceived Stress Scale, which measures self-reported stress. A total of 11,238 respondents completed the interview and returned the questionnaire. Multiple logistic regression analyses were performed to investigate the association between distance to green space and self-perceived stress. Results: Danes living more than 1 km away from the nearest green space report poorer health and health-related quality of life, i.e. lower mean scores on all eight SF-36 dimensions of health than respondents living closer. Respondents living more than 1 km away from a green space have 1.42 higher odds of experiencing stress than do respondents living less than 300 m from a green space. Respondents not reporting stress are more likely to visit a green space than are respondents reporting stress. Reasons for visiting green spaces differ significantly depending on whether or not respondents experience stress. Respondents reporting stress are likely to use green spaces to reduce stress. Conclusions: An association between distance to a green space and health and health-related quality of life was found. Further, the results indicate awareness among Danes that green spaces may be of importance in managing stress and that green spaces may play an important role as health-promoting environments.

Epidemiology of chronic pain in Denmark: An update

The most recent Danish health survey of 2005 is based on a region‐stratified random sample of 10.916 individuals. Data were collected via personal interviews and self‐administrated questionnaires. Respondents suffering from chronic pain were identified through the question ‘Do you have chronic/long‐lasting pain lasting 6 months or more?’ The prevalence of chronic pain among individuals with a present or earlier cancer diagnosis was also assessed. In all, 7275 individuals (66.6%) completed a personal interview and 5552 individuals (50.9% of the original sample) completed and returned the self‐administrated questionnaire. The same questions were included in the survey in 2000 and, hence, it was possible to evaluate the trends in the past five years. In all, 20.2% of the adult Danish population has chronic pain. From year 2000–2005 the prevalence of chronic pain has remained stable. Generally, chronic pain was associated with female gender and increasing age. Higher prevalence of chronic pain were associated with being divorced, separated or widowed, having less than 10 years of education and high BMI. Musculoskeletal diseases (66.8%) were the most common cause for chronic pain and most persons with chronic pain rated their health and quality of life as poor. Persons with earlier or present cancer diagnosis were more likely to report chronic pain. A substantial part of persons with chronic pain were not satisfied with the examinations and treatments offered. In conclusion, over a five‐year period the prevalence of chronic pain in Denmark has remained stable, but high.

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).

Effect of nationwide tobacco control policies on smoking cessation in high and low educated groups in 18 European countries

Background: Recently a scale was introduced to quantify the implementation of tobacco control policies at country level. Our study used this scale to examine the potential impact of these policies on quit ratios in European countries. Special attention was given to smoking cessation among lower educational groups. Methods: Cross-sectional data were derived from national health surveys from 18 European countries. In the analyses we distinguished between country, sex, two age groups (25–39 and 40–59 years) and educational level. Age-standardised quit ratios were calculated as total former-smokers divided by total ever-smokers. In regression analyses we explored the correlation between national quit ratios and the national score on the Tobacco Control Scale (TCS). Results: Quit ratios were especially high (>45%) in Sweden, England, The Netherlands, Belgium and France and relatively low (<30%) in Lithuania and Latvia. Higher educated smokers were more likely to have quit smoking than lower educated smokers in all age-sex groups in all countries. National score on the tobacco control scale was positively associated with quit ratios in all age-sex groups. The association of quit ratios with score on TCS did not show consistent differences between high and low education. Of all tobacco control policies of which the TCS is constructed, price policies showed the strongest association with quit ratios, followed by an advertising ban. Conclusion: Countries with more developed tobacco control policies have higher quit ratios than countries with less developed tobacco control policies. High and low educated smokers benefit about equally from the nationwide tobacco control policies.

The study design and characteristics of the Danish national health interview surveys

Aims: The Danish National Institute of Public Health, University of Southern Denmark has carried out national representative health interview surveys among adult Danes in 1987, 1994, 2000 and 2005. The aim of this study is to describe the characteristics of the design, including the response rates of the four surveys. Methods: The samples in 1987 and 1994 are based on simple random sampling. The samples in 2000 and 2005 are based on stratified random sampling. In addition, all invited to the survey in 1994 were re-invited in both 2000 and 2005. Data were collected via face-to-face interview at the respondent’s home. Following the interview in 1994, 2000 and 2005, all respondents were asked to complete a self-administered questionnaire. Results: The response rate for the face-to-face interview fell from 79.9% in 1987 to 66.7% in 2005 and the response rate for the self-administered questionnaire from 68.1% in 1994 to 51.5% in 2005. The decrease is particularly marked among the young. The mean interview length has increased from 33.3 minutes in 1987 to 50.2 minutes in 2005. Conclusions: The declining response rate in the surveys is a major concern and can pose problems in generalizing data from the surveys to the Danish population. However, these surveys are essential, as the information collected cannot be gathered by means of official statistical registers. Hence, efforts to increase the response rate will be important in the forthcoming surveys.

The Danish National Health Survey 2010.: Study design and respondent characteristics.

Aims: In 2010 the five Danish regions and the National Institute of Public Health at the University of Southern Denmark conducted a national representative health survey among the adult population in Denmark. This paper describes the study design and the sample and study population as well as the content of the questionnaire. Methods: The survey was based on five regional stratified random samples and one national random sample. The samples were mutually exclusive. A total of 298,550 individuals (16 years or older) were invited to participate. Information was collected using a mixed mode approach (paper and web questionnaires). A questionnaire with a minimum of 52 core questions was used in all six subsamples. Calibrated weights were computed in order to take account of the complex survey design and reduce non-response bias. Results: In all, 177,639 individuals completed the questionnaire (59.5%). The response rate varied from 52.3% in the Capital Region of Denmark sample to 65.5% in the North Denmark Region sample. The response rate was particularly low among young men, unmarried people and among individuals with a different ethnic background than Danish. Conclusions: The survey was a result of extensive national cooperation across sectors, which makes it unique in its field of application, e.g. health surveillance, planning and prioritizing public health initiatives and research. However, the low response rate in some subgroups of the study population can pose problems in generalizing data, and efforts to increase the response rate will be important in the forthcoming surveys.

Influence of the recall period on self-reported alcohol intake

Objective: To estimate the accuracy of recall on self-reported alcohol intake.Design: Population-based random sample.Setting: The Danish Health and Morbidity Survey 1994.Subjects: The study is based on 6,354 persons chosen at random among the adult Danish citizens. The response rate was 77%.Main outcome measure: Number of alcoholic drinks consumed on each day during the last week.Results: For self-reported alcohol intake on the last Saturday, respondents with a recall period of one day have the shortest recall period (reference group) and respondents with a recall period of seven days the longest. Respondents with a recall period of seven days reported significant lower alcohol intake (Odds Ratio: 0.56). The reported alcohol intake declines when the recall period increases. The decline in recall of alcohol intake is very clear already after 2–3 days.Conclusion: The systematic decrease in reported alcohol use with increased recall period indicates problems in correctly reporting alcohol intake for a full week. Many surveys use recall periods that are longer than a week and, therefore, underreported alcohol intake is expected to be even higher.

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