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Abstract

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix

Background

Chronic pain constitutes a substantial socio-economic challenge but little is known about its actual cost.

Aim

To estimate the direct and indirect costs of patients with a diagnosis related to chronic pain (DRCP), to determine variation in these costs across different diagnosis groups, and to identify what resources constitute the most important components of costs.

Methods

Patient level data from three administrative registries in Västra Götalandsregionen in Sweden including inpatient and outpatient care, prescriptions, long-term sick-leaves, and early retirement were extracted. Patients with a DRCP between January 2004 and November 2009 were selected.

Results

In total, 840,000 patients with a DRCP were identified. The mean total costs per patient and year were estimated at 6400 EUR but were higher for patients with cancer (10,400 EUR). Patients on analgesic drugs had more than twice as high costs as patients without analgesic drugs, on average. Indirect costs (sick-leaves and early retirement) constituted the largest cost component (59%) followed by outpatient (21%) and inpatient care (14%), whereas analgesic drug prescriptions constituted less than 1 percent of the total.

Conclusions

The socio-economic burden of patients with a diagnosis related to chronic pain amounts to 32 billion EUR per year, when findings from Västra Götalandsregionen are extrapolated to the whole of Sweden. This compares to a fifth of the total Swedish tax burden in 2007 or about a tenth of Swedish GDP. This study does not provide evidence on what costs are caused by chronic pain per se. However, the higher costs of patients on analgesic drugs might indicate that the consequences of pain are of major importance.

1. Introduction

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix

Chronic pain is one of the major health problems of our time. It is highly prevalent in the general population, estimated at 19% in a large European study (Breivik et al., 2006) and it has been reported to be a primary cause of individuals seeking health care in Sweden (Frolund and Frolund, 1986; Von Korff et al., 1991; Elliott et al., 1999). In addition to personal suffering, chronic pain leads to reduced productivity and large health care costs. The Swedish council on health technology assessment (SBU) estimated the societal costs of chronic pain at 9.1 billion EUR in 2003 of which 0.8 billion were direct costs associated with medical care and 8.3 billion were indirect costs from early retirement and sick-leave (SBU, 2006). Other international studies have shown that individuals reporting chronic pain have higher resource utilization than those without chronic pain (Eriksen et al., 2004) but also that patients who are denied disability pensions have higher utilization of health care (Hojsted et al., 1999), and that costs may be reduced by multidisciplinary pain treatment (Thomsen et al., 2002).

Chronic pain may not be viewed as a disease but rather a symptom caused by either of numerous disorders. Together with other symptoms of these disorders, the pain commonly causes costs in terms of e.g. health care contacts or productivity losses. Because the symptoms of a disease are integrated, it is difficult (if at all possible) to determine which of the symptoms is actually causing the cost. Instead, we may alter the perspective and assess the cost of a patient with a disorder commonly causing chronic pain. This will not indicate the costs due to chronic pain per se or even the costs of patients experiencing chronic pain. Instead, it will increase the understanding of the costs of this particular group of patients which can help informing decisions on how health care should be organized for them.

Swedish administrative registries provide high-quality data on health care resource utilization. Patients can be identified based on their diagnosis (International Classification of Diseases, ICD-10), prescriptions received (Anatomic Therapeutic Chemical classification system, ATC), or demographics. This provides a unique opportunity to analyze large samples of patients with a certain disease or treated with a certain compound. The ICD-10 system is insufficient in classifying pain symptoms because most categories consider the underlying diagnosis potentially causing pain but do not categorize the pain per se. With few exceptions, such ICD-10 diagnoses are therefore given both to patients that seek health care due to pain symptoms and patients that do not report pain experience at all. We included all ICD-10 diagnoses commonly causing moderate-severe chronic pain according to a German study (Freytag et al., 2009), and refer to these as diagnoses related to chronic pain (DRCP) throughout this paper.

The objectives of this study were to estimate the societal costs of patients with a DRCP, to determine variation in these costs across different diagnosis groups, and to identify what resources constitute the most important components of costs.

2. Methods

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix

2.1 Study design

Retrospective patient level data were extracted from three Swedish administrative registries: (1) the Vega register from a regional health authority in Western Sweden (Västra Götalandsregionen) with a total population of 1.56 million inhabitants, (2) the national prescriptions register held by the National Board of Health and Welfare (Socialstyrelsen), and (3) the national social insurance register held by the Swedish Insurance Agency (Försäkringskassan). The data available in the registries are summarized in Table 1.

Table 1. Data availability from registries
Data categoryItemsRegisterCoverageTime frame
DemographicsAge and genderVega registerN/AN/A
Inpatient careDates of admission and discharge, primary and secondary diagnoses (ICD-10), and type of wardVega registerVirtually all stays at any hospital within the region (1.56 million inhabitants)January 1st 2004–November 30th 2009
Outpatient careDate of visit, primary and secondary diagnoses (ICD-10), type of medical personnel, and type of clinic/facilityVega registerVirtually all visits to any clinic/care facility (except specific maternal and juvenile care facilities) within the region (1.56 million inhabitants)January 1st 2004–November 30th 2009
PrescriptionsDate of prescription, date of dispatch, ATC-code, strength, administration form, name of drug, and cost of prescriptionNational prescriptions registerAll dispatches from any Swedish pharmacyJuly 1st 2005–November 30th 2009
Sick-leaveStart and end dates, and level of compensation for those on part-time sick-leaveNational social insurance registerAll reimbursed sick-leaves above 14 daysUntil December 31st 2008
Early retirementStart and end datesNational social insurance registerAll reimbursed early retirementsUntil December 31st 2008

The Swedish 10-digit personal code number (personnummer) enabled data to be linked from the three registers. The register holders replaced the personal identifier with a study specific patient number (prepared at the Vega register) before submitting their data to the study team. Thereby, only anonymous data was retrieved from the registries. The study was approved by an ethics committee.

2.2 Patient selection

All patients in the Vega register with any of the diagnoses listed in Appendix A, see the online version at 10.1016/j.ejpain. 2011.07.006, either from their inpatient or outpatient care records between January 1st 2004 and November 30th 2009, were included in the study.

The DRCPs were identified in a German study that explored what diagnoses were related to outpatient opioid treatment in a register sample of about 200,000 patients (Freytag et al., 2009). Because these diagnoses were not considered exhaustive for patients receiving opioid therapy in Swedish practice, 26 additional diagnoses were added by recommendation from a panel of four Swedish pain specialists (personal communication Rivano-Fischer M, Sjolund K-F, Mannheimer C, Nov 2009). This resulted in a list of 149 diagnoses (truncated three-digit ICD-10 codes) which were grouped into nine diagnosis groups according to their assumed association with pain (Appendix A, see the online version at 10.1016/j.ejpain.2011.07.006).

2.3 Resource utilization and costs

Monthly resource utilization was calculated for each patient, by counting the number of outpatient visits, days admitted to hospital, and number of prescriptions. Further, the number of days of work absence due to sick-leave and early retirement per month was calculated by counting the number of week days within each month between the recorded start and end dates.

Monthly costs of care were calculated by multiplying the number of resources used, by their corresponding unit cost. Unit costs for inpatient and outpatient care were collected from regional price lists (Vastra_gotalandsregionen, 2009; Vastra_sjukvardsregionen, 2009). All costs were converted into Euro according to the mean exchange rate in 2008 (1 EUR = 9.6152 SEK) (Eurostat, 2010). Ward-specific per-diem costs were used for inpatient care, ranging between 381 EUR (urologic ward) and 1859 EUR (child and adolescent neurology with habilitation). For outpatient care visits, the per visit cost depended on both the medical personnel and on the type of clinic/facility, ranging between 973 EUR (Specialist intensive care) and 47 EUR (Physical therapist). A full list of unit costs for inpatient and outpatient care is available upon request. For prescriptions, the total cost (including reimbursement from the county council and patient co-payment) of each drug dispatch was considered.

Sick-leave and early retirement is associated with an indirect cost to society. According to the human capital theory, the value of this indirect cost is equal to the production loss from being absent from work. The Swedish gross average wage per day (166 EUR) was therefore considered as the indirect cost of each day of absence.

2.4 Analysis

Complete data from the combined registries were available for 3 years: 2006 through 2008. The mean use of each resource and total costs were calculated for each of these 3 years.

Patients were stratified based on the nine diagnosis groups. Many patients were expected to have multiple diagnoses and were therefore allocated to a diagnosis group based on their first diagnosis. We then selected all patients with their first diagnosis between January 2006 and November 2008. This resulted in a sample of newly diagnosed patients (that is, patients receiving a diagnosis after a period of 2 years without any), which could be followed for at least 1 year. These patients were then stratified according to whether they had a dispatch of any analgesic drug (according to list in Appendix B, see the online version at 10.1016/j.ejpain. 2011.07.006) during the first year following the first diagnosis. This list was reviewed and amended by the panel of pain specialists (personal communication Rivano-Fischer M, Sjolund K-F, Mannheimer C, November 2009), with the purpose to include all prescriptions relevant to pain therapy in Swedish practice. Mean costs over the first year after diagnosis were then calculated for each of the strata.

3. Results

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix

In total, 837,896 unique patients with at least one DRCP (Appendix A, see the online version at 10.1016/j.ejpain.2011. 07.006) were identified in the Vega register. There were more women (56%) than men in the sample and the mean age was 48 years. The age distribution was similar to the general Swedish population (Fig. 1), but the proportion with any of the diagnoses was comparatively lower in the young population and higher in the elderly population.

figure

Figure 1. The age distribution of the identified patients (bars, read from the left axis) compared to the age distribution of the Swedish population (line, read from the right axis).

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From the year 2006–2008, in this sample of patients with a DRCP, there was an increase in the mean number of outpatient visits, acute care visits, and prescriptions. The mean number of days of absence from work due to long term sick-leaves and proportions of working age population in early retirement decreased over time (Table 2). This decrease in sick-leaves and early retirement resulted in an overall decrease in the mean total costs over time (Fig. 2). In 2008, the mean total costs of all patients with any DRCP were 6400 EUR per patient in the year, of which 59% were indirect costs (i.e. costs associated with lost production due to work absence), 6% were drug costs (<1% were costs of analgesic prescriptions), 14% were inpatient care costs and 21% were outpatient care costs (Table 3).

figure

Figure 2. Mean annual costs per patient with a diagnosis related to chronic pain (DRCP), by year and resource type (EUR).

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Table 2. Mean annual use of resources per patient
Resource200620072008
Outpatient care (n visits)7.07.27.4
Acute care (n visits)0.160.170.19
Inpatient care (n days)1.411.411.37
Non-analgesic drugs (n prescriptions)13.614.214.6
Analgesic drugs (n prescriptions)2.02.12.2
Sick leave (n days)8.98.06.7
Proportion of adult (age 18–65) patients on early retirement (%)12.112.111.6
Table 3. Annual mean costs per patient in 2008 by resource and diagnosis group (EUR)
 Any diagnosisDiagnosis groupsa
CancerSpecific back conditionsIntervertebral disc disorderArthritisFracturesMultimorbiditiesHeadachesNeuropathiesOther conditions associated with chronic pain
  1. a

    N.B. Groups include all patients that had a diagnosis in the group as listed in Appendix A. Patients may be allocated to several groups if they had multiple diagnoses.

Number of patients837,89667,61446,08315,746318,58969,25737,03895,57252,158603,563
Direct costs
Outpatient care1332189120772352169515281868161820561446
Acute care35516551376268434539
Inpatient care8963170208811411005155127027451485909
Non-pain prescriptions349805669416439402669323505340
Pain prescriptions3870104116525693438142
Total direct costs2650598850014075322836015400277241712775
Indirect costs
Sick leave112017871367424013221211654149820391248
Early retirement2659267334127409324824102123333245303017
Total indirect costs37794460477911,649457036212777483065694265
Total costs642910,448978115,724779872218177760210,7407040

Many patients were multi-morbid and had diagnoses placing them in several of the diagnosis groups. Most patients (72%) had a diagnosis in the group “Other conditions associated with chronic pain” whereas the smallest group (intervertebral disc disorder) included only 2% of all patients. The highest direct costs were found in patients with a cancer diagnosis whereas patients with an intervertebral disc disorder had the highest indirect and total costs, on average. Patients with no cancer diagnosis (92% of all patients with a DCRP) had a total cost per patient of 6100 EUR in 2008, on average (data not shown).

A third of all patients had their first diagnosis between January 2006 and November 2008 and half of these had an analgesic drug dispatch during the year following their first diagnosis (Table 4). Costs were considerably higher (more than double on average) for patients with an analgesic drug dispatch during the first year after their first diagnosis.

Table 4. Costs during first year from first diagnosis between jan2006-nov2008 (EUR)
 AllDiagnosis group
CancerSpecific back conditionsIntervertebral disc disorderArthritisFracturesMultimorbiditiesHeadachesNeuropathiesOther conditions associated with chronic pain
Number of patients with diagnosis between January 2006 and November 2008318,49212,4564045104169,34416,539617019,1077730182,060
Any pain prescription
Number of patients160,3996597238175944,102775425217566328585,434
% Of all patients with any pain prescription100%4%1%0%27%5%2%5%2%53%
Costs (first year after diagnosis)
Outpatient care2484418923393196242828643034212529072345
Acute care7195727144125106655279
Inpatient care203111,47017161805122623385598102119701686
Non-pain prescriptions4671609554362429443947327526395
Pain prescriptions7921010413467811695212071
Sick leave2741677625988792214933281088212436572699
Early retirement2996285429804279265822932511286041383217
Total costs10,86927,20310,36318,639900111,47313,454857413,36910,493
No pain prescription
Number of patients158,0935859166428225,2428785364911,541444596,626
% Of all patients with no pain prescription100%4%1%0%16%6%2%7%3%61%
Costs (first year after diagnosis)
Outpatient care1542304215191880159016911789126918691433
Acute care514247132810842412356
Inpatient care6213440437211397419874360860542
Non-pain prescriptions2291058287130240154396136256185
Pain prescriptions0000000000
Sick leave1020364373842288758666017212032914
Early retirement13561733162026381412807137386618591395
Total costs482012,95846499101454340455075339468984524
Difference in total costs w/o pain prescription604914,24557149538445874278379518064715969

4. Discussion

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix

This study aimed to estimate the societal costs of patients with a diagnosis related to chronic pain (DRCP). We identified close to 840,000 cases in a geographical region with 1.56 million inhabitants in 2008, which implies that a majority of inhabitants (54%) have received a DRCP in this region. The mean cost per patient and year of these patients were estimated at 6400 EUR in 2008. This sums to 5.4 billion EUR for the whole of this region, constituting about a sixth of Sweden. If these patients are assumed to be representative of the whole of Sweden, the cost can be extrapolated to a national cost of 32 billion EUR. These costs should not be interpreted as the costs due to chronic pain or even due to the underlying disease potentially causing chronic pain, but instead the costs of patients with a diagnosis related to chronic pain.

We also found that the costs during the first year following diagnosis of patients with a DRCP where more than double if the patient was treated with analgesic drugs. The difference of 6000 EUR per patient on average may be interpreted as the additional cost of patients with symptoms that need analgesic drug treatment. Only 79 EUR of these (<2%) were the cost of the actual analgesic drug. The costs of all resources without exceptions (even across all subgroups) were larger if the patient was treated with analgesic drugs. This might indicate that the consequences of the pain per se are of major importance. It would be of interest to identify what part of these additional costs may be reduced by optimal pain therapy, but our study does not allow for any such analysis.

The main component of total costs was the cost of lost production associated with sick leave and early retirement, together accounting for 59% of total costs on average in 2008. Outpatient care costs (21%) and inpatient care costs (14%) also contributed significantly, whereas analgesic prescriptions constituted less than 1 percent of total costs. These findings indicate that the largest potential for cost savings may result from a faster return to work and a more effective management of patients in outpatient care.

We identified a decrease in the mean number of sick-leave days and proportions on early retirement from 2006 to 2008, leading to a decrease in total costs. This is probably in part due to recent initiatives on national levels that are investing in rehabilitation programs that aimed to return people in sick leave back to work (SKL, 2010). Nevertheless, long term sick-leaves and early retirements still constitute the majority of the total costs in our study and an enormous burden to society. In a recent report the Swedish Insurance Agency listed the six most common diagnoses meriting a newly approved sick-leave or early retirement benefit. These included three DRCPs within the “Other conditions associated with chronic pain” group: Other diseases of the spine and back, not classified elsewhere (M53), Back pain (M54), and Other soft tissue disorders, not elsewhere classified (M79) (Forsakringskassan, 2006).

We analyzed data on the total target population in the selected region. Because we did not do any sampling, there is no sampling uncertainty in our estimates and no need for calculating confidence intervals. This is the actual reported resource use in one sixth of Sweden. The results may or may not be representative to the rest of Sweden but this is not dependent on the variation in costs across the observed patients.

According to our knowledge, this is the first study to explore costs of care of the heterogeneous group of patients with a DRCP. Previous studies have assessed the cost of particular disorders causing malignant and non-malignant pain. In comparison, our study has a larger focus encompassing the burden associated with all disorders commonly causing pain.

Our estimate of 32 billion EUR is about four times higher than the 9.1 billion estimated by SBU in 2003. There are a number of important explanations for this discrepancy: (1) our sample considered 54% of the general population whereas SBU considered an estimated 18% of the adult population (above 18 years of age) who met their criteria of chronic pain, (2) we considered the total costs of patients with DRCP whereas SBU estimated the additional costs due to chronic pain, (3) our estimates were based on the observed resource use in registries of 840,000 patients whereas SBU based their calculations on interviews with 300 Swedish adults meeting preset criteria for chronic pain (Breivik et al., 2006) supplemented by a range of assumptions, and (4) we did not consider costs of over-the-counter drugs whereas SBU did not consider inpatient stays, acute care visits or concomitant medication. As a consequence, our estimate should include the costs of a wider range of persons affected by chronic pain but also some costs that are not directly caused by pain itself.

Other comparable studies are less available. One study assessed the cost per adolescent with chronic pain in the UK at £8000 per year in 2004 (Sleed et al., 2005). This higher estimate is partly explained by higher direct costs from more health care contacts. Another study assessed the annual cost of low back pain in Sweden at €20,700 per patient in 2005 (Ekman et al., 2005). Two recent reviews on chronic low back pain did not find sufficient evidence to present a reliable estimate on the cost of this disease (Dagenais et al., 2008; Juniper et al., 2009).

Our sample of patients most likely includes patients that actually do not have any pain symptoms although they have a diagnosis that is commonly causing moderate-severe chronic pain. This limitation is because the ICD-10 system does not differentiate between patients with and without chronic pain, since they share common ICD-10 codes. There are pain-specific diagnosis codes, and in an initiative to enhance the detail of the Swedish ICD-10 coding, the Swedish National board of health and welfare has added three sub-categories to the code for “other chronic pain” (R52.2). In the latest Swedish ICD-10-SE version, the categories now include “chronic pain, nociceptive” (R52.2A), “chronic pain, neuropathic” (R52.2B), and “chronic pain, without known cause” (R52.2C). However, the pain-specific ICD-10 codes are mostly used by specialists and a large proportion of patients suffering from pain never get them. A more specific selection of subjects with chronic pain would therefore probably only be achieved by patient interviews or questionnaires. This limitation is not applicable to other disorders which are better defined by the ICD-10 system, which may make cost studies in such disorders using a similar approach even more attractive.

It would have been of interest to divide the costs for a patient into pain-related and non-pain-related costs. Some resources have a more apparent link to pain than others (e.g. a strong opioid prescription has a more apparent link than a visit to a general practitioner), but it is not possible to fully distinguish resources used due to pain symptoms from resources due to other causes. Many health care contacts probably occur due to a combination of symptoms, which cannot be connected to a specific diagnosis. A potential solution to this problem would have been to identify a control group to compare with our cost estimates. Examining the difference in costs between our sample and another sample, with exactly the same characteristics but without any DRCP, would have indicated the additional cost of having a DRCP. However, the relevance of this comparison is limited by the available information in the registries. Because we only had about 6 years of follow-up, we could not ascertain that patients without a diagnosis within this timeframe would not have an older diagnosis. Moreover, patients in the potential control group may have suffered from chronic pain without ever having received a diagnosis. Such analysis would include, not only the health care registries available for this study but also a registry of all inhabitants from which a reference sample would need to be drawn. Future research may look further into this issue.

The selection of diagnoses was based on a previous study and the opinion of a Swedish expert panel. We believe that most diagnoses associated with chronic pain of clinically significant intensity have been included. The grouping of diagnoses was made for illustrative purposes and their relevance to any stratification outside the scope of this study is limited.

This study had a societal perspective, i.e. we aimed to include all costs. Some resources that may be of significance for total cost estimates were not available from the registries and therefore not considered in the study. These are data on over-the-counter medicines, orthopedic aids and devices, community care services (e.g. home help and transportation), special accommodation, adaptations of homes, household work carried out by an informal caregiver (e.g. family member), reduced work capacity while at work (so called presenteeism), and intangible costs associated with e.g. reduction in quality of life due to the pain. Furthermore, shortterm sick-leave costs (below 15 days) were also not included in this study because they are the responsibility of the employers and therefore are not recorded in the national insurance register. Including these cost items would have further increased the cost per patient.

The three limitations described above include: (1) the insufficiency of the ICD-10 system in identifying patients with chronic pain, (2) the limited data available on what resources are actually caused by chronic pain, and (3) the lack of data on specific items which may be of significance to total costs. Together, they inhibit us from estimating the costs due to chronic pain in this study. Our results should therefore not be interpreted as the costs caused by chronic pain or even the costs of patients with chronic pain. Instead, our estimates show the costs of patients having a diagnosis that is commonly causing pain. Thereby, this paper demonstrates the large challenge that this patient population represents to society. Part of this challenge involves optimizing the management of pain but there are also other aspects of their underlying disorders that need attention.

5. Conclusions

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix

In conclusion, the costs of patients with a diagnosis related to chronic pain were estimated at an annual cost of 6400 EUR per patient and amounts to approximately 32 billion EUR when extrapolated to the whole of Sweden. This compares to a fifth of the total Swedish tax burden in 2007 (155 billion (SCB, 2009)) or about a tenth of Swedish GDP (325 billion (SCB, 2010)). The indirect costs associated with lost production because the patient is absent from work constituted the largest proportion of our cost estimate (about 60%). This study does not provide evidence on what costs are caused by chronic pain per se. However, the higher costs of patients on analgesic drugs might indicate that the consequences of pain are of major importance.

Acknowledgements

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix

The authors would like to thank Åsa Vikingson, Gothia Forum for assisting in the acquisition of data. Thanks also to Brenda Gannon for valuable comments and language edits. The study was funded by an unrestricted research grant from Grünenthal.

References

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix

Appendix

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix
Diagnosis groupsDiagnosis (truncated ICD-10 code)
  1. a

    Diagnosis added by recommendation from Swedish expert panel.

CancerMalignant labial neoplasm (C00), Malignant neoplasm of the base of the tongue (C01), Malignant neoplasm of other non-specified parts of the tongue (C02), Malignant neoplasm of the gums (C03), Malignant neoplasm of the floor of the mouth (C04), Malignant gingival neoplasm (C05), Malignant neoplasm of other non-specified parts of the mouth (C06), Malignant parotid neoplasm (C07), Malignant neoplasm of other non-specified large salivary glands (C08), Malignant tonsillar neoplasm (C09), Malignant oropharyngeal neoplasm (C10), Malignant nasopharyngeal neoplasm (C11), Malignant hypopharyngeal neoplasm (C13), Malignant neoplasm of other imprecisely specified locations of the lips, buccal cavity and pharynx (C14), Malignant oesophageal neoplasm (C15), Malignant neoplasm of the small intestine (C17), Malignant rectal neoplasm (C20), Malignant neoplasm of the anus and anal canal (C21), Malignant neoplasm of the liver and intrahepatic biliary ducts (C22), Malignant neoplasm of other non-specified parts of the biliary tract (C24), Malignant pancreatic neoplasm (C25), Malignant neoplasm of the nasal sinuses and middle ear (C30), Malignant nasal sinus neoplasm (C31), Malignant laryngeal neoplasm (C32), Malignant bronchial and pulmonary neoplasm (C34), Malignant thymus neoplasm (C37), Malignant cardiac, mediastinal and pleural neoplasm (C38), Malignant neoplasm of other or imprecisely specified locations of the respiratory system and other intrathoracic organs (C39), Malignant neoplasm of the bones and joint cartilage of the extremities (C40), Malignant neoplasm of the bone and joint cartilage of other and non-specified locations (C41), Mesothelioma (C45), Kaposi's sarcoma [sarcoma idiopathicum multiplex haemorrhagicum] (C46), Malignant neoplasm of the peripheral nerves and autonomic nervous system (C47), Malignant retroperitoneal and peritoneal neoplasm (C48), Malignant neoplasms of other connective and soft tissues (C49), Malignant vaginal neoplasm (C52), Malignant uterine neoplasm, part not specified (C55), Malignant renal neoplasm, except renal pelvis (C64), Malignant neoplasm of the renal pelvis (C65), Malignant neoplasm of the ureter (C66), Malignant meningeal neoplasm (C70), Malignant cerebral neoplasm (C71), Malignant neoplasm of the spinal cord, cerebral nerves and other parts of the central nervous system (C72), Malignant adrenal neoplasm (C74), Malignant neoplasm of other endocrine glands and related structures (C75), Malignant neoplasm of other or imprecisely specified locations (C76), Secondary and non-specified malignant neoplasm of the lymph nodes (C77), Secondary malignant neoplasm of the respiratory and digestive organs (C78), Secondary malignant neoplasm in other locations (C79), Malignant neoplasm with no specification of the location (C80), Hodgkin's disease [lymphogranulomatosis] (C81), Follicular [nodular] non-Hodgkin lymphoma (C82), Diffuse non-Hodgkin lymphoma (C83), Other and non-specified types of non- Hodgkin lymphoma (C85), Malignant immunoproliferative diseases (C88), Plasmocytoma and malignant plasma cell neoplasms (C90), Myeloid leukaemia (C92), Carcinoma in situ of the buccal cavity, oesophagus and stomach (D00), Carcinoma in situ of other non-specified digestive organs (D01), Carcinoma in situ of the middle ear and respiratory system (D02), Neoplasm of uncertain or unknown behaviour of the middle ear, respiratory and intrathoracic organs (D38), Meningeal neoplasm of uncertain or unknown behaviour (D42), Cerebral and central nervous neoplasm of uncertain or unknown behaviour (D43), Myelodysplastic syndromes (D46), Other neoplasms of uncertain or unknown behaviour of the lymphatic, haemopoietic and related tissues (D47), Immunocompromisation after radiation, chemotherapy and other immunsuppressant treatment (D90), Other medical treatment (Z51),
Specific back conditionsOther deformities of the spine and back (M43), Ankylosing spondylitis (M45), Other inflammatory spondylopathies (M46), Other spondylopathies (M48), Spondylopathies in diseases classified elsewhere (M49), Osteoporosis with no pathological fracture (M81), Osteoporosis in diseases classified elsewhere (M82),
Intervertebral disc disorderCervical intervertebral disc damage (M50), Other intervertebral disc damage (M51),
ArthritisSeropositive rheumatoid arthritis (M05), Other forms of rheumatoid arthritis (M06), Psoriatic arthritis and arthritis in primary gastrointestinal diseases (M07), Juvenile arthritis (M08), Gouta (M10), Other crystal arthropathiesa (M11), Other specified joint diseases (M12), Other forms of arthritis (M13), Joint diseases in other diseases classified elsewhere (M14), Rheumatoid arthritis (M15), Osteoarthritis of the hip (M16), Osteoarthritis of the knee (M17), Osteoarthritis of the base of the thumb (M18), Other forms of arthritis (M19), Internal derangement of kneea (M23), Other specified joint damage (M24), Other joint diseases not classified elsewhere (M25), Systemic connective tissue diseases in diseases classified elsewhere (M36), Other enthesopathiesa (M77), Gait and mobility disorders (R26),
FracturesCervical fracture (S12), Fracture of the rib(s), sternum and thoracic spine (S22), Fracture of the lumbar spine and pelvis (S32), Fracture of the shoulder and upper arm (S42), Dislocation, sprain and strain of joints and ligaments of shoulder girdlea (S43), Dislocation, sprain and strain of joints
 and ligaments of elbowa (S53), Fractures involving several regions of the body (T02), Fracture of the spine, level not specified (T08), Sequelae of injuries of the neck and body (T91),
MultimorbiditiesBed sores (L89), Leg ulcers, not classified elsewhere (L97), Other dermal and subcutaneous diseases, not classified elsewhere (L98), Osteoporosis with pathological fracturea (M80),
HeadachesMigraine (G43), Other headache syndromes (G44), Headache (R51),
NeuropathiesTrigeminal neuropathies (G50), Diseases of other cerebral nerves (G52), Cerebral neuropathies in diseases classified elsewhere (G53), Nerve root and plexus diseases (G54), Nerve root and plexus compression in diseases classified elsewhere (G55), Mononeuropathies of the upper extremity (G56), Mononeuropathies of the lower extremity (G57), Other mononeuropathies (G58), Mononeuropathy in diseases classified elsewhere (G59), Hereditary and idiopathic neuropathy (G60), Polyneuritis (G61), Other polyneuropathies (G62), Other polyneuropathies (G62), Polyneuropathy in diseases classified elsewhere (G63), Other diseases of the peripheral nervous system (G64), Paraplegia and tetraplegiaa (G82), Postprocedural disorders of nervous system, not elsewhere classifieda (G97), Other disorders of bone (M89), Other symptoms and signs involving the nervous and musculoskeletal systemsa (R29),
Other conditions associated with chronic painSomatoform disordera (F45), Other disorders of central nervous systema (G96), Spondylosis (M47), Other diseases of the spine and back, not classified elsewhere (M53), Back pain (M54), Soft tissue disorders related to use, overuse and pressurea (M70), Shoulder lesionsa (M75), Other soft tissue disorders, not elsewhere classifieda (M79), Biomechanical lesions, not elsewhere classifieda (M99), Pain in throat and chesta (R07), Abdominal and pelvic paina (R10), Pain, not elsewhere classifieda (R52), Dislocation, sprain and strain of joints and ligaments at neck levela (S13), Complications of other internal prosthetic devices, implants and graftsa (T85), Other complications of surgical and medical care, not elsewhere classifieda (T88), Sequelae of injuries of upper limba (T92), Sequelae of injuries of lower limba (T93), Sequelae of injuries involving multiple and unspecified body regionsa (T94),

Appendix

  1. Top of page
  2. Abstract
  3. 1. Introduction
  4. 2. Methods
  5. 3. Results
  6. 4. Discussion
  7. 5. Conclusions
  8. Acknowledgements
  9. References
  10. Appendix
  11. Appendix
Analgesic drug treatments: Substance (ATC-code)
Aceklofenac (M01AB16), Acetylslicylic acid (ASA) (N02BA01), Alfentanil (N01AH02), Amitriptyline (N06AA09), Buprenorphine (N02AE01), Celecoxib (M01AH01), Codeine (R05DA04), Codeine comb. excl. psychotropics (N02AA59), Codeine combined with acetylsalicylic acid (N02AA66), Codeine combined with diclofenac (N02AA65), Codeine combined with paracetamol (N02AA69), Codeine combined with propyphenazone (N02AA64), Dexibuprofen (M01AE14), Dextropropoxyphene (N02AC04), Dextropropoxyphene, comb. excl. psycholeptics (N02AC54), Dihydrocodeine (N02AA08), Diklofenac (M01AB05), Diklofenac, combinations (M01AB55), Duloxetine (N06AX21), Etoricoxib (M01AH05), Fentanyl (N02AB03), Fentanyl (N01AH01), Fenylbutazone (M01AA01), Flunixin (M01AG90), Gabapentine (N03AX12), Glukosamine (M01AX05), Hydromorphone (N02AA03), Hydromorphone and antispasmodics (N02AG04), Ibuprofen (M01AE01), Ibuprofen, combinations (M01AE51), Imipramine (N06AA02), Indometacin (M01AB01), Ketobemidon (Ketogan Novum) (N02AB01), Ketogan (N02AG02), Ketoprofen (M01AE03), Ketorolac (M01AB15), Klomipramine (N06AA04), Lofepramine (N06AA07), Lornoxicam (M01AC05), Lumiracoxib (M01AH06), Maprotiline (N06AA21), Meloxicam (M01AC06), Metadon (tablet) (N07BC02), Morphine (N02AA01), Morphine and antispasmodics (N02AG01), Nabumetone (M01AX01), Nalbuphine (N02AF02), Naproxen (M01AE02), Nortriptyline (N06AA10), Oxycodone (N02AA05), Oxycodone combined with naloxone (N02AA55), Paracetamol (N02BE01), Paracetamol combination (Citodon) (N02BE51), Parecoxib (M01AH04), Pethidine (N02AB02), Piroxicam (M01AC01), Pregabaline (N03AX16), Sufentanil (N01AH03), Sulindac (M01AB02), Tenoxicam (M01AC02), Tolfenamic acid (M01AG02), Tramadol (N02AX02), Tramadol/Tilidate combinations (N02AX52), Trimipramine (N06AA06), Venlafaxine (N06AX16), Tenoxikam (M01AC02), Tolfenamsyra (M01AG02), Tramadol (N02AX02), Tramadol/Tilidate combinations (N02AX52), Trimipramin (N06AA06), Venlafaxin (N06AX16)