Perceptions of treatment, accompanying symptoms, and other problems in patients with chronic pain: a multicenter cross-sectional study in Korea

Abstract

Background

Chronic pain significantly affects daily activities, mental health, and the interpersonal relationships of patients. Consequently, physicians use various treatments to manage pain. This study investigated the perceptions of treatment, accompanying symptoms, and other problems in patients with chronic pain.

Methods

The authors enrolled patients with chronic pain from 19 university hospitals in South Korea. Data was collected on age, gender, diagnosis, disease duration, severity of pain, perception of pain treatment, and accompanying symptoms or problems using an anonymous survey comprising 19 questions.

Results

In total, 833 patients with chronic pain completed the survey, and 257 (31.0%) and 537 (64.5%) patients expressed concerns about the potential adverse effects of medication and opioid addiction, respectively. Personality changes such as irritability or anger were the most frequent accompanying symptoms in 507 (63.8%) patients, followed by depression and sleep disturbance in 462 (58.1%) and 450 (54.5%) patients, respectively. Depression (P = 0.001) and anxiety (P = 0.029) were more common among women, whereas divorce (P = 0.016), family conflict (P < 0.001), unemployment (P < 0.001), suicide attempts (P < 0.001), and restrictions on economic activity (P < 0.001) were more common among men. The frequency of accompanying symptoms, except for suicidal ideation, was higher in the younger patients aged ≤ 40 years than in the older patients aged > 40 years.

Conclusions

Many patients with chronic pain had concerns about adverse effects or medication tolerance and experienced anxiety, depression, or sleep disturbances. The prevalence of accompanying problems varies according to age and gender.

INTRODUCTION

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage [1]. Acute pain can be considered an alarm system reflecting tissue damage and inflammation in the body, whereas chronic pain is a disease. Chronic pain can be accompanied by psychiatric disorders, such as depression and anxiety, which significantly impact the daily life and quality of life of patients [2]. Many patients with chronic pain also experience additional difficulties in terms of interpersonal relationships or economic activity [3]. Although patients with chronic pain may experience various issues, the knowledge among physicians regarding the frequency and severity of these problems in patients remains limited.

Pain physicians employ diverse methods, including medication and nerve block, to effectively manage pain in patients. Furthermore, various medications, including general painkillers, anticonvulsants, and antidepressants, are also used. Moreover, opioid analgesics are used to treat severe pain. Notably, prescriptions of opioid analgesics have recently increased in Korea, simultaneously increasing the concerns about opioid use [4]. Patients also express concerns about opioid use, including adverse effects, dependency, and addiction [5,6]. Meanwhile, differences in patients' knowledge and practice may influence procedures such as nerve blocks [7]. Therefore, knowing patients' perceptions of treatment is crucial for providing appropriate information to patients, helping them understand, and increasing compliance.

This study aimed to explore the perceptions of treatment and accompanying symptoms experienced by patients with chronic pain. Multiple symptoms accompanying pain, involving mental symptoms, such as depression and anxiety, as well as social issues, such as divorce and unemployment were investigated. Furthermore, fear of adverse effects among patients was also examined. Notably, better understanding of patients' perception may help establish more appropriate treatment and management strategies, and the findings of this study may contribute to the improvement in the quality of life of patients with chronic pain.

MATERIALS AND METHODS

This study included the data from a nationwide survey conducted by the Public Committee of the Korean Pain Society (KPS) involving patients with chronic pain from 19 university hospitals who visited their pain clinics. The survey was conducted through a KPS committee meeting and was based on a previous survey conducted by the Pain Society in 2011. It was revised to gather the patients' perceptions of treatment, symptoms, and accompanying problems. Physicians in each hospital explained the contents of the questionnaires to patients with chronic pain and distributed them to those who agreed to complete the questionnaire. Questionnaires were collected over a period of approximately 2 months, from July to August 2021. The need for ethical approval for this study was waived by the Institutional Review Board of the Konkuk University Medical Center (IRB no. KUMC 2024-01-045). Based on the results of this anonymous survey in 2021, this manuscript was drafted in 2024.

This multicenter cross-sectional study targeted patients who visited the pain clinic of a university hospital with chronic pain. Chronic pain was defined as pain lasting for > 6 months. Patients who did not agree to participate or those aged < 20 years were excluded.

In addition to the survey questions, the information about diagnosis, duration of illness, age, gender, and whether the patient lived with family was collected. The questionnaire consisted of 19 items, including questions on the time taken for diagnosis, number of hospitals visited prior to diagnosis, pain severity, and sleep interference. Eight questions were about the types of pain medication they used and their thoughts about medication, and one question was about their perception of nerve block treatment. Five questions were about accompanying problems, including psychiatric symptoms and difficulties in interpersonal relationships. The detailed contents of the survey questionnaire are presented in Appendix.

The frequency of each symptom was determined based on the patient responses. The authors then analyzed the differences in symptom prevalence between different age groups and genders. Statistical analyses were performed using SPSS 17. The chi-square test and Student's t-test were employed to evaluate proportional and mean differences, respectively. P ≤ 0.05 was considered statistically significant.

RESULTS

1. Demographic characteristics

In total, 833 patients, including 425 women (51.0%) and 408 men (49.0%), participated in the survey from July to August 2021. The average age of the patients was 57.3 ± 15.8 years. The average pain level, duration of illness, and sleep time were 5.9 ± 2.4, 75.4 ± 89.0 months, and 5.9 ± 1.8 hours per day, respectively. Table 1 describes demographic characteristics of the participants.

Table 1.

Demographic characteristics of patients

Characteristics		Value
Gender (n = 833)	Women	425 (51.0)
	Men	408 (49.0)
Age, yr (n = 823)	20–29	40 (4.9)
	30–39	86 (10.4)
	40–49	145 (17.6)
	50–59	152 (18.5)
	60–69	195 (23.7)
	70–79	144 (17.5)
	80–89	61 (7.4)
Age (yr)		57.3 ± 15.8
Morbidity period (mo)		75.4 ± 89.0
NRS score		5.9 ± 2.4
Sleep time (hr/day)		5.9 ± 1.8

Values are presented as number (%) or average ± standard deviation.

NRS: numeric rating scale.

According to the diagnostic classification, 377 (46.0%) patients had neuropathic pain. The neuropathic pain group included 115 patients with complex regional pain syndrome (CRPS), 66 with postherpetic neuralgia, 65 with peripheral neuropathy (such as intercostal neuralgia, diabetic polyneuropathy, ulnar/median/radial neuropathy, and meralgia paresthetica), 60 with radiculopathy, 59 with failed back surgery syndrome, and 12 with trigeminal neuralgia. Furthermore, 304 (37.2%) and 46 (5.6%) patients had spinal and joint diseases, respectively. In addition, 30 (3.7%), 16 (2.0%), 12 (1.5%), and 9 (1.1%) patients had fibromyalgia, cancer pain, headache, and myofascial pain syndrome, respectively. The proportions of patients classified according to their diagnoses are presented in Fig. 1.

Fig. 1.

Proportions of patients according to the diagnosis. MPS: myofascial pain syndrome.

2. Treatment perception

Fig. 2 presents the perceptions of patients about pain medication. Notably, 200 patients (24.2%) answered that enduring pain was better than taking medication, and 628 patients (75.8%) answered the opposite. Furthermore, 319 (38.5%) patients were not worried about the adverse effects of pain control medication, whereas 253 (30.5%), 187 (22.6%), and 70 (8.4%) patients were slightly, moderately, and highly worried about the adverse effects of pain control medication, respectively. Additionally, medication was changed in 235 patients (23.8%) due to adverse effects. A total of 268 (32.6%) patients were taking opioids, and 629 (76.0%) patients considered it acceptable to use opioids for severe pain. Moreover, 537 patients (64.5%) believed that the use of opioids may lead to addiction. Additionally, 700 (86.2%) patients believed that nerve block treatment was helpful in treating pain, and 109 (13.4%) responded that it was ineffective (Fig. 3).

Fig. 2.

Perception about pain medication among participants. S/E: side effect.

Fig. 3.

Opinion about nerve block among participants.

3. Prevalence of accompanying problems

Personality changes such as anger or irritation were the most common symptoms accompanying chronic pain, with approximately two-thirds of the patients (507, 63.8%) experiencing personality changes, followed by depression (462 patients, 58.1%) and sleep disturbances (450 patients, 54.5%). Furthermore, 38.7% of patients experienced financial difficulties, and 10.3% lost their jobs due to pain. In addition, patients with chronic pain had difficulties with their relationships, and 76 (9.6%) and 17 (2.1%) patients experienced family conflict and divorce due to chronic pain, respectively. Fig. 4 presents the prevalence of the accompanying problems. Moreover, 351 (42.2%) patients exhibited suicidal ideation, and 87 (10.50%) patients attempted suicide (Fig. 5). A total of 315 (37.9%) and 306 (37.0%) patients answered ‘yes’ to the question whether they face any difficulties because their family and friends did not understand their pain, respectively (Fig. 6).

Fig. 4.

Prevalence of the accompanying problems among participants.

Fig. 5.

Prevalence of suicidal ideation and suicidal attempts among participants.

Fig. 6.

Prevalence of difficulties with people around them because of pain among participants.

Among the problems accompanying chronic pain, some were more common in women and others in men. Table 2 shows the differences in the prevalence of each symptom between groups. Some psychiatric symptoms, such as anxiety (P = 0.029) and depression (P = 0.001), were more common among women, whereas problems with social relationships, such as divorce (P = 0.016) and family conflict (P < 0.001), were more common among men. Additionally, problems related to economic activity, such as unemployment (P < 0.001), financial difficulty (P < 0.001), and restrictions in economic activity (P < 0.001), were more common among men. No statistically significant difference for personality change, which was the most commonly experienced symptom, was observed between men and women. Notably, suicidal ideation had a similar prevalence among men and women, whereas the prevalence of suicide attempts was significantly higher among men (14.5%) than women (6.7%) (P < 0.001).

Table 2.

Comparison of problems accompanying chronic pain between women and men

Accompanying problem	Women (n = 425)	Men (n = 408)	P value
Divorce	4 (1.0)	13 (3.4)	0.016
Family conflict	25 (6.1)	51 (13.4)	< 0.001
Unemployment	27 (6.6)	55 (14.4)	< 0.001
Economic activity limitation	132 (32.1)	174 (45.7)	< 0.001
Financial difficulty	68 (16.5)	104 (27.3)	< 0.001
Suicidal attempt	28 (6.7)	59 (14.5)	< 0.001
Anxiety	188 (45.7)	148 (38.8)	0.029
Depression	263 (64.0)	199 (52.2)	0.001
Personality change	256 (62.3)	251 (65.9)	0.164
Distraction, memory impair	178 (43.3)	150 (39.4)	0.146
Incomprehension of friend	154 (36.5)	152 (37.7)	0.385
Incomprehension of family	168 (39.7)	145 (35.8)	0.138
Suicidal idea	169 (39.9)	181 (44.8)	0.085
Sleep disorder	218 (51.8)	230 (57.2)	0.068

Values are presented as number (%).

Symptom prevalence varied according to the age group. Notably, the participants were classified into two age groups—the younger age group, including participants aged ≤ 40 years, and older group, including participants aged > 40 years—to compare the prevalence of each symptom or accompanying problem [8–10]. Notably, most symptoms were more common in the younger age group. In particular, the prevalence of anxiety and suicidal ideation was higher in the younger age group, although the difference was not statistically significant. Furthermore, younger patients experienced personality changes (P = 0.001), depression (P < 0.001), and sleep disorders (P = 0.004) more frequently than older patients. The prevalence of unemployment, family conflict, and divorce was more than twice as high in the younger group as in the older group. Table 3 presents the comparison between the age groups.

Table 3.

Comparison of problems accompanying chronic pain between the younger (aged ≤ 40 years) and older (> 40 years) groups

Accompanying problem	Forties or below (n = 265)	Over forties (n = 522)	P value
Distraction, memory impair	133 (50.2)	192 (26.8)	0.001
Personality change	191 (72.1)	313 (60.0)	0.001
Depression	181 (68.3)	278 (53.3)	< 0.001
Financial difficulty	77 (29.1)	92 (17.6)	0.001
Economic activity limitation	132 (49.8)	172 (33.0)	< 0.001
Unemployment	46 (17.4)	34 (6.5)	< 0.001
Family conflict	39 (14.7)	37 (7.1)	0.002
Divorce	11 (4.2)	6 (1.1)	0.021
Suicidal attempt	47 (17.7)	40 (7.7)	< 0.001
Incomprehension of friend	118 (44.5)	186 (35.6)	0.017
Sleep disorder	168 (62.0)	279 (51.0)	0.004
Incomprehension of family	118 (44.5)	195 (37.4)	0.055
Suicidal idea	128 (48.3)	221 (42.3)	0.101
Anxiety	124 (46.8)	209 (40.0)	0.176

Values are presented as number (%).

DISCUSSION

This study investigated the perceptions of patients with chronic pain about the treatment and accompanying symptoms, including difficulties in daily life and interpersonal relationships. The authors’ findings revealed that 61.5% of the patients had various degrees of concern about the adverse effects of the medication, and 28.3% of patients changed their medication due to adverse effects. A total of 268 (32.6%) patients were taking opioid medications, and most respondents believed that it was reasonable to use opioids for severe pain. In contrast, 537 (64.5 %) patients believed that the medical use of opioids could cause addiction. Additionally, 700 (86.5%) patients believed that the nerve block treatment was effective.

More than half of patients experienced personality changes, depression, and sleep disorders. However, the prevalence of some problems differed among men and women. Additionally, the frequency of related symptoms or problems was higher in younger patients than in older patients.

Pain physicians use various medications, including general painkillers, antidepressants, anticonvulsants, and opioid analgesics, to manage chronic pain. However, the adverse effects of these medications can make treatment more difficult. The perceptions of patients regarding medical treatments were explored through this study. Notably, the majority of patients had concerns regarding adverse effects, although the degree of concern varied. These concerns have also been reported in previous studies. For instance, a study on the perception of patients about the painkiller use patterns revealed that some patients took less than prescribed doses because of concerns about adverse effects or tolerance [6,11]. Notably, such negative thoughts can affect drug compliance and even the treatment course besides the actual adverse effects. These concerns were inversely associated with adherence to medical care [11,12]. Therefore, pain physicians should consider patients’ discomfort with medication and attempt to provide suitable medications individually.

Opioids are frequently prescribed for chronic pain, and concerns about the use of opioid medication commonly occur among patients [13,14]. Centers for Disease Control and Prevention recommend exercising extreme caution when prescribing opioids to patients with non-cancer chronic pain [15]. Notably, opioid use for chronic pain is increasing in Korea [16]. Therefore, the authors also investigated the status and awareness about opioid use in this study. A total of 32.6% of the patients with chronic pain were taking opioid medication, and 64.5% of the patients believed that prescribed opioids could cause addiction.

In a previous study on patient perceptions of opioid medications, patients who did not take opioid medications cited fear of addiction as the reason [5]. In the present study, 39% of patients responded no to the question whether they would take opioids if prescribed by their doctor due to concerns about adverse effects and addiction. Notably, many patients were afraid of opioid addiction.

In a previous study on opioid prescriptions, 98.6% of Korean pain physicians reported prescribing opioids, and most of them actively explained the adverse effects of opioids. Although uncommon, physicians were mostly concerned with opioid addiction and misuse [17]. Additionally, the patients were mostly worried about the opioid addiction as the adverse effect; however, the most common adverse effects were constipation and nausea/vomiting, indicating a difference between the adverse effects that patients were concerned about and those commonly reported. Patients and doctors tend to have greater concerns about addiction than about its actual prevalence [17]. Notably, providing appropriate information to patients and prescribing medications according to the guidelines is crucial [18,19].

In this study, the majority (86.5%) of the patients who received nerve block treatment responded that it was effective. However, concerns about adverse effects of nerve block and whether the patients had an accurate understanding of the procedure were not investigated in this study. A domestic study that investigated patients’ perceptions of steroid injections reported that a large number of patients received information about treatment through the media rather than physicians [7]. Consequently, some patients had incorrect or negative perceptions about the procedure. Hence, providing information through sufficient explanations by doctors is crucial to prevent negative perceptions about the treatment among patients, which ultimately affects treatment compliance.

Patients with chronic pain experience various problems affecting their quality of life. Psychiatric diseases, particularly depression, are common among patients with chronic pain [20,21]. In this study, more than half of the patients reported experiencing depression, and a significant number of patients had suicidal ideation and attempted suicide. Patients with pain have a significantly higher risk of suicide than normal individuals [22]. A review article published in the UK reported a two times higher incidence of suicide in patients with chronic pain than in the controls, with a prevalence of lifetime suicide attempts of 5%–14% [2]. Sleep disturbance was also highly prevalent among the patients with chronic pain, and previous studies on spinal disease and CRPS have also reported a higher incidence of insomnia [23–25].

Many patients with chronic pain have difficulty engaging in economic activities. Patients experience economic limitations, financial difficulties, and unemployment. In a study on chronic pain and high-impact chronic pain (chronic pain that frequently limits life or work activities) conducted in the US, 31.5% and 16.5% of the patients with chronic pain and high-impact chronic pain, respectively, experienced unemployment [26]. Another study involving a survey on patients with CRPS reported that many patients experienced unemployment and financial difficulties after the onset of the disease and had difficulty performing activities of daily living due to pain, with 80.5% of the patients experiencing suicidal ideation [25].

In this study, the authors also observed gender-related differences in comorbidities and symptoms. Women experienced more anxiety and depressive symptoms than men, where men experienced higher financial and relational problems, such as divorce, family discord, and job loss. These results may be attributed to the fact that a higher proportion of men engage in economic activities in Korea than women [27]. Previous studies have reported that men patients with pain are more likely to develop mood disorders and drug addiction [28], whereas the prevalence of factors affecting depression, anxiety, and chronic pain was reported to be higher in women than in men in another cross-sectional study [29]. Further research in this context is warranted owing to the limited related studies and inconsistent results.

The frequency of accompanying symptoms was higher in the younger patients than in the older patients. Notably, younger individuals aged < 40 years are sensitive to various symptoms caused by pain, further affecting their interpersonal relationships and economic concerns. Difficulties with social activities in younger patients because of pain can be a serious social issue requiring appropriate treatment. A study examining differences in pain perception according to age in Europe, involving three age groups (< 40, 40–65, and > 65 years), showed similar tendencies. However, the proportion of participants reporting depressive symptoms was significantly lower in the older age group, and the individuals in the older group exhibited higher pain acceptance than the younger and middle-aged groups [30].

This study also has some limitations. First, separately obtaining data for the items that were actually diagnosed, such as depression or sleep disorders, would be more accurate regardless of whether the patients had subjective symptoms or if they had actually been diagnosed. Second, although various accompanying problems were assessed to investigate the effect of pain on the quality of life of the patients, it would be easier to correlate and compare them with other data employing generally used tools. Third, regarding medication perception, only pain control drugs were included. Data on anxiolytics, antidepressants, or sleep-inducing drugs were not collected. It should be noted that the symptoms accompanying these drugs can also affect patients. Fourth, patients’ attitudes towards psychotherapeutic methods were not assessed. The authors focused only on medications and nerve blocks. Finally, as this study involved patients who visited a university hospital, the severity of pain and frequency of accompanying symptoms may differ from the patients with general chronic pain.

In conclusion, this study investigated the difficulties experienced by patients with chronic pain, concerns regarding medication, and opinions regarding the efficacy of treatment. Although accurate evaluation of pain is crucial for the management of patients with chronic pain, recognizing and making efforts to resolve other difficulties in their lives are equally important.

Funding Statement

FUNDING No funding to declare.