Pain and postgraduate medicine

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In the last +40 years, we have witnessed an increasing interest toward Pain Medicine. Physicians have started to care for pain patients, with mixed success. The data on pain epidemiology are still merciless [1,2], and pain impact on society is impressive [3], including the ability of pain patients to participate in active and productive lives [4]. Obviously, the quality of life for patients with chronic pain is poor [5,6], especially for some pain syndromes [7]. Physical disability in chronic pain patients is one of the worst issues [6], but also psychological and psychiatric co-morbidities are very important and synergistic with the negative effects of chronic pain [5,8]. Still, cancer pain remains a problem, especially when neuropathic pain is present [9,10].

The pathophysiology of pain syndromes in every type of chronic pain is increasingly complex [11,12] which makes it challenging to tailor correct therapies for the right patients [13]. Age is an important factor that increases chronic pain incidence, and elderly patients deserve special attention [14], mainly when affected by cognitive decline [15]. Interesting new data on the interconnections between degenerative joint diseases and neuroinflammation may represent the basis for a different vision and therapeutic approach for one of the most diffuse problems, which is osteoarthritis [16]. Inflammation still represents the key aspect in many cases [17], and this has increased scientists’ interest toward different aspects involved in the inflammatory process, like microglia, also for potential treatment entanglements [18].

Based on that, the vast majority of general physicians and specialists involved in pain management are still treating patients in pain with the classical approach based on pharmacological therapy represented by non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, sometimes supplemented by adjuvant drugs. This is the approach suggested long ago in the guidelines set out by the World Health Organization (WHO) that were initially published in 1986 and have been criticized by many. It has also generated an epigenetic modification in health-care professionals for its extreme simplicity and simplistic approach. It is clear, very little has changed in the epidemiology of pain (especially chronic pain) [19], which suggests a need for a new vision, which has been a clear issue for the last 10 years[20].

However, change seems to be on the horizon [21]. An increasing attention to effectiveness and safety of treatments is emerging [17], which has led to a more careful selection of drugs [22] based on an increased knowledge of their side effects and ways to prevent them [23]. The concept of multimodal pharmacological analgesia is increasingly clear [24–25], as it is suggested the necessity of combining pharmacological treatment with other possible therapies to ameliorate the final results [26–28]. This may be particularly useful in very complex pain syndromes [29–30].

The content of this ‘Special Issue’ of Postgraduate Medicine covers some of these developments. The paper of Danilov et al. [31] addresses a crucial aspect in the management of chronic pain patients in the form of a multidisciplinary approach. Without the successful collaboration of the different medical specialties, any potential management for chronic pain will fail.

The use and abuse of benzodiazepines in pain patients is extensively discussed in the article by Pergolizzi and LeQuang [32]. Benzodiazepines have been suggested as adjuvant drugs in pain management. Unfortunately, their use has become an abuse in many occasions. The authors make this concept very clear and provide an insight into what happens in these circumstances.

Interventional pain management has become a reality, especially after the ‘opioid crisis.’ This is true for chronic non-cancer pain patients [33,34], but especially for cancer pain, as reminded by the two articles published in this issue [35,36].

The importance of pathophysiology is clear in the management of pain as well as comprehension of the mechanisms of action that these therapies target. In the last article of this issue, the authors discuss the mechanisms and modes of action used to control neuropathic pain by spinal cord stimulation [37]. This modality of therapy is an excellent supplement to the pharmacological treatments. As such, it should always be looked at with interest by pain physicians.

That said, I am sure our readers will enjoy this special issue, with its comprehensive and interdisciplinary approach to treating patients with chronic pain. Pain may be reduced or vanquished only with an open-minded approach, using all the potentialities that modern medicine can provide.

Conflict of interest

The author declares that he does not have any conflict of interest connected to the content of the article.

Declaration of interest

The contents of the paper and the opinions expressed within are those of the author, Giustino Varrassi, and it was the decision of the author to submit the manuscript for publication.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The author is grateful to the Paolo Procacci Foundation for its support in the preparation of this manuscript. Moreover, he expresses his gratitude to Mike Gregg of Taylor & Francis for his kind revision of the English language.