Chronic pain
Types of chronic pain
Cancer pain
It has been estimated that cancer pain can be managed effectively in most patients by the appropriate use of the World Health Organization (WHO) guidelines,1-4 but it continues to be under-treated in many patients.5,6
Non-cancer pain
The analgesic ladder is used to guide prescribing of analgesics in cancer pain, but it is also appropriate for patients with non-cancer pain. Patients with mild pain may be adequately controlled with non-opioid analgesics,moderate pain can be treated with weak opioids and, if weak opioids have failed to provide relief, strong opioids can be considered. NB It should be stressed that opioids are not first-line therapy for persistent non-cancer pain, nor are they recommended as the only treatment.
Osteoarthritis and pain
It is reported that 81% of people with osteoarthritis suffer constant pain or are limited in their scope to perform everyday tasks.7 When their osteoarthritis pain is bad, 69% of osteoarthritis patients surveyed said that they would have difficulty carrying out household tasks and just over 50% said that they even struggled to get out of bed.7 Almost half (48%) said that they would need to have frequently unbearable pain levels before they presented to a doctor.7 Patients suffering from osteoarthritis may experience pain around the joints that can be debilitating, and when asked to spontaneously name the qualities looked for in a medicine, 82% wanted a medicine that offered good pain relief and 20% wanted a medicine to help them with their mobility.7
Postoperative pain
It is recognised that a significant number of patients experience inadequate pain relief after surgery.8 Patients in pain suffer more complications after surgery, which can lead to a longer hospital stay.8 There is increasing evidence that improved analgesia may be associated with less morbidity and mortality, and with lower costs of hospitalisation.8 Accumulated data support the use of opioids for patients with postoperative pain.9-15 Several recent reviews discuss the use of multimodal analgesia (i.e. the combination of analgesics that have different mechanisms of action, such as opioids, non-steroidal anti-inflammatory drugs and local anaesthetics) for the treatment of postoperative pain.16-18 The evidence they present suggests that multimodal analgesia is more effective than the use of single analgesics.
References:
1) World Health Organization. Cancer pain relief: with a guide to opioid availability. 2nd ed. Geneva: The World Health Organization; 1996.
2) Ventafridda V, Tamburini M, Caraceni A, et al. A validation study of the WHO method for cancer pain relief. Cancer 1987; 59:850-6.
3) Walker VA, Hoskin PJ, Hanks GW, et al. Evaluation of WHO analgesic guidelines for cancer pain in a hospital-based palliative care unit. J Pain Symptom Manage 1988; 3:145-9.
4) Schug SA, Zech D, Dörr U. Cancer pain management according to WHO analgesic guidelines. J Pain Symptom Manage 1990; 5:27-32.
5) Cherny NI, Catane R. Professional negligence in the management of cancer pain. A case for urgent reforms [editorial]. Cancer 1995; 76:2181-5.
6) Regaard A. The principles of pain management in advanced cancer. Br J Community Nurs 2000; 5:382-8.
7) Arthritis Care. OA Nation: the most comprehensive UK report of people with osteoarthritis. The Organisation. Available from: URL: http://www.arthritiscare.org.uk/PublicationsandResources/OANation/Downloads/main_content/OA_Nation_report.pdf.
8) Rawal N. Postoperative pain and its management. In: Rawal N, editor. Management of acute and chronic pain. London: British Medical Journal Books; 1998. p.51-88.
9) Sunshine A, Olson NZ, Colon A, et al. Analgesic efficacy of controlled-release oxycodone in postoperative pain. J Clin Pharmacol 1996;36:595-603.
10) Curtis GB, Johnson GH, Clark P, et al. Relative potency of controlled-release oxycodone and controlled-release morphine in a postoperative pain model. Eur J Clin Pharmacol 1999; 55:425-9.
11) Cheville A, Chen A, Oster G, et al. A randomized trial of controlled-release oxycodone during inpatient rehabilitation following unilateral total knee arthroplasty. J Bone Joint Surg 2001; 83-A:572-6.
12) McCroskery E, Kaiko R. Open-label, clinical-use study of controlled-release (CR) oxycodone in patients with postoperative pain. Proceedings of the 9th World Congress on Pain; 1999 Aug 22-27; Vienna, Austria. Seattle: IASP Press®; 1999. p. 606.
13) Napp Pharmaceuticals Limited. A randomised, double-blind, parallel group, multicentre study to compare the tolerability, safety and efficacy of oxycodone with morphine in patients using i.v. patient-controlled analgesia (PCA) for acute postoperative pain. Data on file, study code: OXI3201.
14) Morrison JD, Loan WB, Dundee JW. Controlled comparison of the efficacy of fourteen preparations in the relief of postoperative pain. BMJ 1971; 3:287-90.
15) Kalso E, Pöyhiä R, Onnela P, et al. Intravenous morphine and oxycodone for pain after abdominal surgery. Acta Anesthesiol Scand 1991; 35:642-6.
16) Jin F, Chung F. Multimodal analgesia for postoperative pain control. J Clin Anesth 2001; 13:524-39.
17) Chauvin M. State of the art of pain treatment following ambulatory surgery. Eur J Anaesthesiol 2003; 20 (suppl 28):3-6.
18) Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183:630-41.