Chronic Pain Media Backgrounder

How can chronic pain be described?
The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”¹ while their definition of chronic pain is that which has “persisted beyond normal tissue healing time”.²

Acute pain, for example with broken limbs or postoperative pain, is usually very intense, but lasts only a short time and generally goes away as healing occurs. However chronic pain – such as cancer pain and lower back pain - is present for long periods of time, defined as pain that occurs continuously or intermittently for three months or more.

Unfortunately these definitions do little to illustrate what chronic pain really feels like for patients and the impact it can have on their lives. Pain patients have described their pain as “devastating”, “agonising”, “torturous” and “intense”.³ Chronic pain can lead to such despair for patients that one in five people living with the condition are depressed.³ Alarmingly many patients say that their pain is so bad that they want to die, and as many as 15 million Europeans consider suicide as a direct result of pain.³

What is the impact of chronic pain?
As stated by the European Federation of IASP chapters (EFIC), pain is a major healthcare problem in Europe. Around one in five of the entire population across Europe suffers from chronic pain on a daily basis.³

Although acute pain may be considered a symptom of disease or injury, chronic pain is a specific healthcare problem and a disease in its own right. This is highlighted by the fact that the World Health Organisation has declared “Treatment to alleviate chronic pain is a human right”.⁴ Yet despite this many chronic pain patients still say they have not achieved adequate pain control.

The impact of the chronic pain on a patient’s quality of life can be devastating, making it difficult or impossible to undertake any number of activities that many of us take for granted. The condition can affect a person’s independence, forcing them to rely on others- one quarter of patients say they are unable to take as much care of themselves or others as they would like. Half report feelings of helplessness, or an inability to think or function normally.3 27% are able or unable to maintain relationships with friends and family, while almost a fifth are no longer able to have sexual relations.³

One in five patients has lost a job as a result of their pain,³ and the cost to the economy as a result of reduced productivity and time off work is considerable. Chronic pain accounts for nearly 500 million lost working days at a cost of at least €34 billion each year to the European economy.³

Why is it important that chronic pain patients receive treatment?
Pain is one of the most frequent reasons people seek help from a doctor or other healthcare professional. Despite this, in many countries, patients do not receive appropriate levels of treatment owing to a range of factors, including inadequate evaluation, poor assessment and inconsistent monitoring. As a result, almost two-thirds of chronic pain sufferers experience inadequate pain control,³ with 28% even reporting they do not feel their doctors know how to control their pain.³

Research shows that the undertreatment of pain can have many serious consequences, including: physiological complications, such as muscle breakdown and weakness; psychosocial impairments, including anxiety and depression, and; an overall decrease in quality of life.⁵

What treatments are available for patients with chronic pain?
Pain management needs to be undertaken as part of a multidisciplinary approach that addresses the pain itself, as well as the underlying cause. Indeed, in many cases (such as arthritis), the disease is incurable, so symptomatic relief becomes the primary goal of treatment. In addition, it is important that appropriate steps are taken to prevent chronification of acute pain.

Medicines such as paracetamol and aspirin provide pain relief for many types of mild to moderate pain, including muscle pain and bone pain.

Opioids such as morphine, oxycodone, hydromorphone, buprenorphine, and fentanyl are effective medicines for relieving severe chronic pain. These medicines may be combined with non-opioid drugs such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDS) for the treatment of moderate chronic pain, and used alone or in combination with other drugs (adjuvant or unconventional analgesics such as antidepressants and corticosteroids) and therapies for severe chronic pain.

How do physicians decide on appropriate treatments for patients?
In the mid 1980s the World Health Organization developed the ‘Analgesic Ladder’,⁶ a stepwise approach to the treatment of cancer pain. Its principles are often applied when prescribing treatments for chronic pain:
Step 1 – Mild to moderate pain
Management of low to moderate pain should start with regular administration of non-opioid analgesics, if this doesn’t provide sufficient pain relief, a weak opioid should be added.
Step 2 – Moderate to severe pain
Patients with this type of pain or those who have not responded to the first step should receive an opioid indicated for moderate pain. These medications may include codeine, dextropropoxyphene and tramadol.
Step 3 – Severe pain
Patients with severe pain who have not achieved pain relief from the previous step will usually receive an opioid such as morphine, oxycodone, hydromophone, methadone or fentanyl.

The WHO also stress that treatment should be:

• By the mouth – Oral therapies should be used where possible
• By the clock – Medications for persistent pain should be administered on an around the clock basis, with additional “as-needed” doses if required, to maintain a consistent level of drug within a patients body, helping to prevent a recurrence of pain.
• By the ladder – Patients with moderate to severe pain when first seen by the clinician should be started at the second or third step of the ladder

As a basic guide, the WHO ladder is of great value, and has helped millions of patients across the world obtain relief from their pain. The ladder however was instituted almost 20 years ago and understanding has moved on.

Discussion amongst specialists has questioned whether the WHO second analgesic step is an optimal treatment protocol, or whether is should be modified so as to proceed directly from NSAIDs to strong opioids in the face of unrelieved pain.⁷ This approach is supported by a recent study which suggested that patients with advanced cancer pain, who were treated with strong opioids as first line treatment, had significantly better pain relief, fewer changes in therapy and were more satisfied with their treatment, than patients treated according to the WHO guidelines.⁸

References:

1. Merskey H. Pain terms: a list with definitions and notes on usage recommended by the IASP subcommittee on taxonomy. Pain 1979; 6: 249–252
2. International Association for the Study of Pain. Classification of chronic pain. Pain 1986; Suppl 3: S1–S226
3. Pain In Europe (www.painineurope.com)
4. World Health Organization, 11th October 2004 (www.who.int/mediacentre/news/releases/2004/pr70/en/)
5. Ashburn M President in press release, American Pain Society. www.ampainsoc.org/whatsnew/031502.htm
6. World Health Organization 1986. Cancer pain relief: Geneva.
7. Eisenberg E, Berkey CS, Carr DB et al. Efficacy and safety of nonsteroidal antiinflammatory drugs for cancer pain: a meta-analysis. J Clin Oncol 1994; 12: 2756–2765
8. Marinangeli F, Ciccouui, A, Leonardis M, Aloisio L, Mezzei A, Paladini A, Porzio G, Marchetti P, Varrassi G. Use of Srong Oioids in Avanced Cancer Pain: A Randomized Trial. J pain Sym Man 27(5): 409–416 (2004)

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