Reframing chronic pain as a disease, not a symptom: rationale and implications for pain management

ABSTRACT

Chronic pain is a common public health problem that has a detrimental impact on patient health, quality of life (QoL), and function, and poses a substantial socioeconomic burden. Evidence supports the redefinition of chronic pain as a distinct disease entity, not simply a symptom of injury or illness. Chronic pain conditions are characterized by three types of pain pathophysiology (i.e. nociceptive, neuropathic, and centralized pain/central sensitization) influenced by a cluster of coexisting psychosocial factors. Negative risk/vulnerability factors (e.g. mood or sleep disturbances) and positive resilience/protective factors (e.g. social/interpersonal relationships and active coping) interact with pain neurobiology to determine patients’ unique pain experience. Viewing chronic pain through a biopsychosocial lens, instead of a purely biomedical one, clinicians need to adopt a practical integrated management approach. Thorough assessment focuses on the whole patient (not just the pain), including comorbidities, cognitive/emotional/behavioral characteristics, social environment, and QoL/functional impairment. As for other complex chronic illnesses, the treatment plan for chronic pain can be developed based on pain subtype and psychosocial profile, incorporating pharmacotherapy and self-management modalities. Preferred pharmacologic treatment of conditions primarily associated with nociception (e.g. osteoarthritis) includes acetaminophen and non-steroidal anti-inflammatory drugs, whereas preferred pharmacologic treatment of conditions primarily associated with neuropathy or central sensitization (e.g. fibromyalgia) includes tricyclic compounds, serotonin-norepinephrine reuptake inhibitors, and α₂δ ligands. Education, exercise, cognitive behavioral therapy, and many other non-pharmacological approaches, alone or combined with pharmacotherapy, have been shown to be effective for any type of pain, although they remain underutilized due to lack of awareness of their benefits and reimbursement obstacles.

KEYWORDS:

• Chronic pain
• neuropathy
• central sensitization
• analgesia
• self-management

Declaration of interest

Daniel J. Clauw has received consulting fees from Pfizer, Cerephex, Tonix, Abbott, Aptinyx, Daiichi Sankyo, Intec Pharma, Samumed, Zynerba, Astellas Pharma, Williams & Connolly LLP, and Therevance. He has also received research support from Pfizer, Aptinyx, and Cerephex. Margaret Noyes Essex and Verne Pitman are employees of Pfizer Inc. Kim D. Jones has received research or education funding from the Department of Defense (PT160162), the NIH/NICHD (RO1 HD082200 01A1), Greenwich Biosciences, and Pfizer Inc. Editorial support was provided by Donna McGuire of Engage Scientific Solutions and was funded by Pfizer Inc. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial relationships to disclose.

Additional information

Funding

Development of this manuscript was funded by Pfizer Inc.