Pharmacological treatment of chronic pain – the need for CHANGE

Abstract

Background:

Although chronic pain affects around 20% of adults in Europe and the USA, there is substantial evidence that it is inadequately treated. In June 2009, an international group of pain specialists met in Brussels to identify the reasons for this and to achieve consensus on strategies for improving pain management.

Scope:

Literature on chronic pain management was reviewed, and information presented to and discussed by a panel of experts.

Findings:

It was agreed that guidelines are not universally accepted by those involved in pain management, and pain treatment seems to be driven mainly by tradition and personal experience. Other factors include poor communication between patients and physicians, the side effects of analgesic drugs, and limited individualisation of therapy. Difficulty in maintaining the balance between adequate pain relief and acceptable tolerability, particularly with strong opioids, can lead to the establishment of a ‘vicious circle’ that alternates between lack of efficacy and unpleasant side effects, prompting discontinuation of treatment. The medical community’s understanding of the physiological differences between nociceptive pain and neuropathic pain, which is often more severe and difficult to treat, could be improved. Increasing physicians’ knowledge of the pharmacological options available to manage these different pain mechanisms offers the promise of better treatment decisions and more widespread adoption of a multi-mechanistic approach; this could involve loosely combining two substances from different drug classes, or administering an analgesic with two different mechanisms of action. In some circumstances, a single compound capable of addressing both nociceptive and neuropathic pain is desirable.

Conclusions:

To improve patient outcomes, a thorough understanding of pain mechanisms, sensitisation and multi-mechanistic management is required. Universal, user-friendly educational tools are therefore required to familiarise physicians with these topics, and also to improve communication between physicians and their pain patients, so that realistic expectations of treatment can be established.

Key words::

• Chronic pain
• Communication
• Educational tools
• Multi-mechanistic treatment
• Neuropathic pain
• Vicious circle

Transparency

Declaration of funding

This article was supported by an unrestricted educational grant from Grünenthal GmbH, Aachen, Germany.

Declaration of financial/other relationships

All authors have disclosed that they received honoraria from Grünenthal for attending the International CHANGE PAIN Advisory Board meeting in Brussels.

The CMRO peer reviewers 1 and 2 have received honoraria for their review work on this manuscript. Both have disclosed that they have no relevant financial relationships.

Acknowledgements

The authors thank Derrick Garwood Ltd, Cambridge, UK, for editorial support, which was sponsored by Grünenthal GmbH, Aachen, Germany.

This Commentary is based on the Proceedings of the International CHANGE PAIN Advisory Board Meeting, held in Brussels, Belgium, on June 7th and 8th, 2009.