Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:43–45. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2013.879245
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
A Decade of Pain Management: Many Achievements But Further Breakthroughs Are Yet to Come Elon Eisenberg A B STRA CT Advances in pain management over the preceding decade are described. Topics identified include special populations—especially the elderly, pain education, neuromodulation, improved understanding of neuronal plasticity, and neuroimaging. Needs not yet met are also described, including improved prescribing and recognition of adverse drug events. Future considerations discussed include analgesics with new mechanisms of action, and application of genetic and psychophysical methods. This report is adapted from paineurope 2013; Issue 3, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS advances, genetics, geriatrics, neuromodulation, neuroimaging, pain, pharmacotherapy
paineurope joint editor Professor Elon Eisenberg reflects on the past decade with his views on what has been achieved and offers predictions on developments in pain in the next 10 years. In celebrating 10th anniversary of paineurope, the editors of the publication provide their views on the top 10 achievements in the area of pain medicine in the past decade. This list highlights just some of the areas in which progress has been made, and in so doing sheds light on the continuous and imperative developments made in many aspects of pain medicine. At the same time, however, the absence of several other topics also suggests areas that suffer from insufficient progress. While pointing to recent advances in the understanding of geriatric pain, Dr. Dagmar Westerling emphasizes the recognition that although pain is a universal experience, distinct populations of patients—the elderly in this case—have special requirements for pain management. Dr. Westerling also
stresses the importance of new observational, behavioral, and rating tools as potential contributors to better quality of care in special populations. In a broader view, improved pain assessment also includes the introduction of diagnosis-specific questionnaires, appropriate clinical examination, and the use of relevant tests, all of which have led to new, improved, diagnostic criteria for conditions such as neuropathic pain, complex regional pain syndrome (CRPS), and fibromyalgia.
IMPROVED PAIN EDUCATION Although insufficient, major changes have also occurred in education on pain diagnosis and treatment at multiple levels. Pain is being included in the core curricula of many nursing and medical schools. Postgraduate education in pain can be found not only in specialties traditionally associated with pain such as anesthesiology or neurology, but also in other medical areas such as orthopedics, family medicine, and others. (Indeed, Dr. Martin Johnson stresses the huge role of primary care in managing the bulk of pain cases in many countries, in which advice on
Elon Eisenberg, MD, is Director, Pain Research Unit, Rambam Medical Centre, and Associate Professor of Neurology, Rappaport Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel. Address correspondence to: Dr. Elon Eisenberg, Pain Research Unit, Rambam Medical Centre, Haifa 31096, Israel. (E-mail: e eisenberg@rambam. health.gov.il).
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Journal of Pain & Palliative Care Pharmacotherapy
self-management is a key part of this.) Pain courses, at local, national, and international levels—such as EFIC (The European Federation of IASP [International Association for the Study of Pain] Chapters) Pain Schools—provide additional education. These educational efforts have led to a dramatic increase in awareness amongst health care providers of the need for, and possibilities of, optimal pain management. The mention of the large-scale international PAINOUT registry on postoperative pain management by Professor Margarita Puig highlights a desperate need to fill gaps in knowledge on how to manage pain in “real life.” It is now obvious that this question cannot and will not be answered by standard randomized controlled trials even when they are performed at high scientific levels. The recently published initial results of PAIN-OUT should encourage the launch of additional registries in other areas of pain medicine such as long-term use of opioids. Major advances have been recorded in specific areas of pain therapy, especially in neuromodulation. Dr. Karen Simpson points to better understanding of how to safely and effectively administer drugs intrathecally in patients with otherwise intractable pain. We now have clear evidence-based data on efficacy of neuromodulation techniques such as spinal cord stimulation for neuropathic back pain or intractable migraine. Lastly, we now begin to see how knowledge obtained in basic science studies is gradually transited to clinical science and practice. Two examples of this transition have been mentioned. Professor Puig’s allusion to the use of genetically engineered pro-enkephalin–expressing herpes simplex virus as a means of pain therapy, which is now being tested in clinical trials in humans, seems almost science fiction. A second transition, mentioned by myself, relates to the concept that neural plasticity is a basic mechanistic principle underlying many chronic painful conditions. Initially introduced by basic scientists, this concept has been broadly adopted by clinicians who already use agents aimed at reversing plastic changes in the central nervous system (CNS). Ketamine administration in patients with CRPS is one example. Through use of advanced neuroimaging techniques, studies have demonstrated different patterns of “pain matrix” plasticity in the brains of people with painful conditions. It is likely that these findings will begin to be utilized clinically within the next few years, perhaps as biological markers of specific pain states, and possibly allowing better adjustments of specific treatments to specific individuals, a concept known as “personalized pain medicine.”
NEEDS STILL TO BE MET Having said this, one fundamental component of pain medicine is conspicuous by its absence from the top10 list: pharmacotherapy. There may be two major reasons for this: firstly, although many molecules targeting newly discovered potentially analgesic sites have shown promising results in animal studies, none has become clinically available. Therefore, the need of clinicians to prescribe novel drugs with new mechanisms of action remains unmet. Secondly, although new developments related to existing classes of analgesics have been made, most of them have been counterbalanced by disadvantages associated with their use. Thus, the broad use of cyclooxygenase inhibitors (coxibs) at the beginning of the last decade, which was based on their markedly improved gastrointestinal (GI) safety profile relative to the traditional nonsteroidal anti-inflammatory drugs (NSAIDs), was quickly wiped out by the discovery of their increased cardiovascular risks, especially with prolonged use. Similarly, conflicting developments have arisen with opioids: on one hand, the availability of the oxycodone/naloxone combined tablet in some countries has offered the opportunity of opioid treatment for patients who otherwise could not use these drugs due to constipation. On the other, there have been reports, mainly from North America, indicating that opioids can be associated with increased risk of death, especially at high dosages. These have raised serious concerns related to their usage in patients with chronic pain. Lastly, newer adjuvant drugs (namely, serotonin-norepinephrine reuptake inhibitor [SNRI] antidepressants and various anticonvulsants) have raised hopes for more effective therapy for difficult conditions such as neuropathic pain but have consistently failed to show improved efficacy (measured by numbers needed to treat [NNTs]) compared with older adjuvant drugs. Another area that cannot be said to number among recent advances in pain management is a change in the availability of pain services. In many countries, patients still have to travel long distances or wait long periods of time (even many months) to be seen by a pain specialist. This is due to the fact that availability of pain services is still much lower than that of other medical specialties. Although it is true that the global financial crisis is slowing down the development of medicine in general, one would still expect governments to channel resources to the so-far disregarded area of pain medicine. This unfortunately has not happened in the past decade.
Journal of Pain & Palliative Care Pharmacotherapy
European Perspectives on Pain and Palliative Care
LOOKING AHEAD So finally, what can we hope for or expect to happen in the pain field over the next decade? Given the extent of ongoing research and the increasing numbers of caregivers who see pain as their main profession, we can expect a lot will happen. Analgesic drugs based on novel mechanisms will likely become available for clinical use. Neuromodulation techniques will advance further. Genetic, neuroimaging, and psychophysical methods will probably be used for individualized pain medicine; that is, to predict the development of pain syndromes or the response to a given therapy. Evidence-based medicine and more
45
registries will allow the development of better guidelines for treatment of different painful conditions. Pain education, for both health care professionals and patients, is likely to improve even more. The big question, though, is whether or not all this will eventually lead to better outcomes. Or, in other words, will there be less pain in the world? More sophisticated and improved means for pain control will almost certainly be there. Will they become accessible and properly used? That is another question. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
Copyright of Journal of Pain & Palliative Care Pharmacotherapy is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
A Decade of Pain Management: Many Achievements But Further Breakthroughs Are Yet to Come Elon Eisenberg A B STRA CT Advances in pain management over the preceding decade are described. Topics identified include special populations—especially the elderly, pain education, neuromodulation, improved understanding of neuronal plasticity, and neuroimaging. Needs not yet met are also described, including improved prescribing and recognition of adverse drug events. Future considerations discussed include analgesics with new mechanisms of action, and application of genetic and psychophysical methods. This report is adapted from paineurope 2013; Issue 3, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS advances, genetics, geriatrics, neuromodulation, neuroimaging, pain, pharmacotherapy
paineurope joint editor Professor Elon Eisenberg reflects on the past decade with his views on what has been achieved and offers predictions on developments in pain in the next 10 years. In celebrating 10th anniversary of paineurope, the editors of the publication provide their views on the top 10 achievements in the area of pain medicine in the past decade. This list highlights just some of the areas in which progress has been made, and in so doing sheds light on the continuous and imperative developments made in many aspects of pain medicine. At the same time, however, the absence of several other topics also suggests areas that suffer from insufficient progress. While pointing to recent advances in the understanding of geriatric pain, Dr. Dagmar Westerling emphasizes the recognition that although pain is a universal experience, distinct populations of patients—the elderly in this case—have special requirements for pain management. Dr. Westerling also
stresses the importance of new observational, behavioral, and rating tools as potential contributors to better quality of care in special populations. In a broader view, improved pain assessment also includes the introduction of diagnosis-specific questionnaires, appropriate clinical examination, and the use of relevant tests, all of which have led to new, improved, diagnostic criteria for conditions such as neuropathic pain, complex regional pain syndrome (CRPS), and fibromyalgia.
IMPROVED PAIN EDUCATION Although insufficient, major changes have also occurred in education on pain diagnosis and treatment at multiple levels. Pain is being included in the core curricula of many nursing and medical schools. Postgraduate education in pain can be found not only in specialties traditionally associated with pain such as anesthesiology or neurology, but also in other medical areas such as orthopedics, family medicine, and others. (Indeed, Dr. Martin Johnson stresses the huge role of primary care in managing the bulk of pain cases in many countries, in which advice on
Elon Eisenberg, MD, is Director, Pain Research Unit, Rambam Medical Centre, and Associate Professor of Neurology, Rappaport Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel. Address correspondence to: Dr. Elon Eisenberg, Pain Research Unit, Rambam Medical Centre, Haifa 31096, Israel. (E-mail: e eisenberg@rambam. health.gov.il).
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Journal of Pain & Palliative Care Pharmacotherapy
self-management is a key part of this.) Pain courses, at local, national, and international levels—such as EFIC (The European Federation of IASP [International Association for the Study of Pain] Chapters) Pain Schools—provide additional education. These educational efforts have led to a dramatic increase in awareness amongst health care providers of the need for, and possibilities of, optimal pain management. The mention of the large-scale international PAINOUT registry on postoperative pain management by Professor Margarita Puig highlights a desperate need to fill gaps in knowledge on how to manage pain in “real life.” It is now obvious that this question cannot and will not be answered by standard randomized controlled trials even when they are performed at high scientific levels. The recently published initial results of PAIN-OUT should encourage the launch of additional registries in other areas of pain medicine such as long-term use of opioids. Major advances have been recorded in specific areas of pain therapy, especially in neuromodulation. Dr. Karen Simpson points to better understanding of how to safely and effectively administer drugs intrathecally in patients with otherwise intractable pain. We now have clear evidence-based data on efficacy of neuromodulation techniques such as spinal cord stimulation for neuropathic back pain or intractable migraine. Lastly, we now begin to see how knowledge obtained in basic science studies is gradually transited to clinical science and practice. Two examples of this transition have been mentioned. Professor Puig’s allusion to the use of genetically engineered pro-enkephalin–expressing herpes simplex virus as a means of pain therapy, which is now being tested in clinical trials in humans, seems almost science fiction. A second transition, mentioned by myself, relates to the concept that neural plasticity is a basic mechanistic principle underlying many chronic painful conditions. Initially introduced by basic scientists, this concept has been broadly adopted by clinicians who already use agents aimed at reversing plastic changes in the central nervous system (CNS). Ketamine administration in patients with CRPS is one example. Through use of advanced neuroimaging techniques, studies have demonstrated different patterns of “pain matrix” plasticity in the brains of people with painful conditions. It is likely that these findings will begin to be utilized clinically within the next few years, perhaps as biological markers of specific pain states, and possibly allowing better adjustments of specific treatments to specific individuals, a concept known as “personalized pain medicine.”
NEEDS STILL TO BE MET Having said this, one fundamental component of pain medicine is conspicuous by its absence from the top10 list: pharmacotherapy. There may be two major reasons for this: firstly, although many molecules targeting newly discovered potentially analgesic sites have shown promising results in animal studies, none has become clinically available. Therefore, the need of clinicians to prescribe novel drugs with new mechanisms of action remains unmet. Secondly, although new developments related to existing classes of analgesics have been made, most of them have been counterbalanced by disadvantages associated with their use. Thus, the broad use of cyclooxygenase inhibitors (coxibs) at the beginning of the last decade, which was based on their markedly improved gastrointestinal (GI) safety profile relative to the traditional nonsteroidal anti-inflammatory drugs (NSAIDs), was quickly wiped out by the discovery of their increased cardiovascular risks, especially with prolonged use. Similarly, conflicting developments have arisen with opioids: on one hand, the availability of the oxycodone/naloxone combined tablet in some countries has offered the opportunity of opioid treatment for patients who otherwise could not use these drugs due to constipation. On the other, there have been reports, mainly from North America, indicating that opioids can be associated with increased risk of death, especially at high dosages. These have raised serious concerns related to their usage in patients with chronic pain. Lastly, newer adjuvant drugs (namely, serotonin-norepinephrine reuptake inhibitor [SNRI] antidepressants and various anticonvulsants) have raised hopes for more effective therapy for difficult conditions such as neuropathic pain but have consistently failed to show improved efficacy (measured by numbers needed to treat [NNTs]) compared with older adjuvant drugs. Another area that cannot be said to number among recent advances in pain management is a change in the availability of pain services. In many countries, patients still have to travel long distances or wait long periods of time (even many months) to be seen by a pain specialist. This is due to the fact that availability of pain services is still much lower than that of other medical specialties. Although it is true that the global financial crisis is slowing down the development of medicine in general, one would still expect governments to channel resources to the so-far disregarded area of pain medicine. This unfortunately has not happened in the past decade.
Journal of Pain & Palliative Care Pharmacotherapy
European Perspectives on Pain and Palliative Care
LOOKING AHEAD So finally, what can we hope for or expect to happen in the pain field over the next decade? Given the extent of ongoing research and the increasing numbers of caregivers who see pain as their main profession, we can expect a lot will happen. Analgesic drugs based on novel mechanisms will likely become available for clinical use. Neuromodulation techniques will advance further. Genetic, neuroimaging, and psychophysical methods will probably be used for individualized pain medicine; that is, to predict the development of pain syndromes or the response to a given therapy. Evidence-based medicine and more
45
registries will allow the development of better guidelines for treatment of different painful conditions. Pain education, for both health care professionals and patients, is likely to improve even more. The big question, though, is whether or not all this will eventually lead to better outcomes. Or, in other words, will there be less pain in the world? More sophisticated and improved means for pain control will almost certainly be there. Will they become accessible and properly used? That is another question. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
Copyright of Journal of Pain & Palliative Care Pharmacotherapy is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
