A major challenge for a generous welfare system: A heavy socio‐economic burden of chronic pain conditions in Sweden – and how to meet this challenge

In this issue of the European Journal of Pain, Gustavsson and co-workers publish an interesting and important study based on data from administrative databases from half (54%) of the 1.6 million inhabitants in the Västra Götaland region of Sweden (Gustavsson et al., 2012). These databases provided patient-level direct and indirect costs to the healthcare and welfare systems of 840,000 patients with one or more diagnoses that commonly are associated with prolonged pain, for the years 2004–2009. Costs were for direct inpatient and outpatient care, drug prescriptions, long-term (more than 15 days) sick leaves, and early retirements. The average annual total costs per patient were €6400, higher for cancer patients (€10,400). But cancer patients were only 8% of all patients with diagnoses associated with chronic pain. Patients receiving analgesic drugs, and therefore likely suffering more intense pain, had more than twice the total costs compared with patients not prescribed analgesic drugs. The mean added costs of those with most severe pain were €6000 compared with those patients who were not prescribed analgesic drugs. Still, the costs for pain-relieving medication were less than 1% of the total. Indirect costs (sick leaves and early retirements) were almost 2/3 of the total, outpatient care was 1/5 and inpatient care 14/100 of all costs. The total costs may well have been considerably higher because many sources of extra costs were not included in the databases. Examples are over-the-counter medicines, orthopaedic aids and devices, community care services such as home care and transportation, presenteeism (i.e., reduced work capacity while at work), intangible costs associated with reduction in quality of life due to pain, shorter sick leaves than 15 days (which in Sweden is the responsibility of the employers). When extrapolated to all of Sweden, the annual total costs were €32 × 109, which was about 1/5 of the total annual tax burden in Sweden in 2007 and about 1/10 of the total gross domestic product GDP (GDP). The fact that patients prescribed analgesic drugs caused twice the total amount compared with those patients who were not prescribed analgesic drugs, indicates that more severe pain per se increased total cost of these patients. This was not due to the cost of analgesic drugs, but to increased indirect costs. This study confirms findings of other studies attempting to estimate total costs of painful health conditions. Pain is the most frequent cause of patients seeking help from the healthcare system (Mäntyselkä et al., 2001). Chronic pain is prevalent in the Nordic countries (Gunnarsdottir et al., 2010). The indirect costs of caring for patients with chronic pain conditions are the major part of the total economic burden to healthcare and welfare systems in Sweden, Finland, Denmark, United Kingdom and Ireland (Mäntyselkä et al., 2002; Thomsen et al., 2002; Eriksen, 2002; Ekman et al., 2005; Phillips and Harper, 2011; Raftery et al., 2011). Studies show that the large indirect costs can be reduced significantly if patients with complex pain conditions are treated in multidisciplinary pain rehabilitation programme (Thomsen et al., 2002; Eriksen, 2004). The PRIME study in Ireland has documented a similar cost per patient with the most severe pain conditions (€10,545) and an estimated total cost for Ireland of more than 2% of the GDP (Raftery et al., 2011; Charles Normand, pers. comm.). Complete cure of chronic, complex pain conditions is often not possible. However, it is established that large savings, especially in the indirect costs, can be made also by a reduction in severity of the pain condition (Charles Normand, pers. comm.). In Copenhagen, Eriksen and co-workers documented that the savings of total cost for the healthcare and welfare systems are twice the cost of managing the chronic pain patients in a multidisciplinary rehabilitation programme (Thomsen et al., 2002; Eriksen, 2004). With these facts in mind and considering the huge economic burden on society of chronic pain conditions (Ekman et al., 2005; Gustavsson et al., 2012; Phillips and Harper, 2011), it is difficult to understand why our healthcare politicians do not invest in more high-quality pain management facilities. Instead, shrinking healthcare budgets reduce resources for chronic suffering patients much more than resources for acute care: The story has always been like this: When resources necessary to save limbs and lives are consumed, there are only tiny leftovers for chronic diseases (McQuay, 2008). Gustafsson and co-workers in this issue of the European Journal of Pain show that the costs of analgesic drugs are a minute fraction (less than 1%) of the total costs to society from the care of patients with diagnoses often associated with chronic painful conditions. It is therefore strange indeed that the healthcare authorities in some of the Nordic countries now strive to reduce reimbursement of costs of analgesic and antihyperalgesic drugs to chronic pain patients. Analgesic drugs are only part of the management of patients with chronic pain (Eriksen, 2004), and among patients with components of neuropathic pain, only half experience meaningful pain relief from drugs and many are burdened with adverse effects (Dworkin et al., 2010). Still, these drugs are important for overall well-being of many patients with chronic pain; patients' global assessment of improvement is often positive; and abilities to be more physically active (Breivik et al., 2010) and to take part in other aspects of their rehabilitation programme may improve (Dworkin et al., 2010). Our healthcare policymakers, who are concerned with the rising cost of health care, should worry more about how to reduce the big indirect costs of patients with chronic health problems associated with pain, rather than trying to shrink the minor expenses for drugs and high-quality pain management programmes. Even if the patients cannot be cured or relieved completely of their pain condition, investment in optimal care for these patients, reducing the total socio-economic burden of the ‘epidemic of chronic pain’ (Gunnarsdottir et al., 2010), will be prudent investments in the healthcare budgets (Eriksen, 2004).