Pharmacological Management of Chronic Pain: How to Deal with the Catch-22 Situation

Abstract

Management of chronic pain is multidisciplinary, but pharmacotherapy is one of the mainstays of pain management. As applies in all medical therapies, clinicians must strive to achieve the best possible outcome for patients in terms of maximising benefit and minimizing risks, and ensure that this is conducted for each treatment and as an integral element in selecting appropriate therapies. If the balance between risk and benefits is not achieved and understood by the patient.
 Chronic pain patients may already experience a degree of stigmatisation, which can be further exacerbated by evolving socio-political pressures in respect of analgesic availability and accessibility. Hence, we have a Catch-22 situation in which patients become ensnared; they may need supervised access to legitimate analgesic medication(s) but these are not easily accessible because of concerns of the analgesic side-effects and abuse/misuse potential influencing both the individual and wider society. 
 In this paper, we review the evidence in respect of analgesic use in chronic pain. We highlight the importance of: 1) better education and awareness of the problem, 2) evaluate the balance between effect and side effects rather than focusing on pain intensity alone, and include such composite measures in clinical trials, 3) identification of responders to treatment and systematic monitoring for misuse and 4) the use of big data to guide politicians away from inappropriate regulatory restrictions. Such a strategy will improve pain treatment and due to the major costs associated with chronic pain it will also be of benefit for society.

Iatrogenic Side Effects of Pain Therapies

“…Drugs remain the mainstay in the armamentarium against pain [ 23 ]. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective pain relievers but may result in gastrointestinal side effects.…”

“…Other side effects associated with opioids include somnolence, nausea, vomiting, dizziness, pruritus, respiratory depression, and the risks of opioid use disorder, tolerance, and dependence [ 2 , 31 ]. These side effects can be treatment limiting and have limited the prescribing of opioids to inappropriate patients [ 23 ]. The determination of the intensity, severity, and tolerability of opioid-associated adverse events is based on the patient’s subjective impressions.…”

Update on pain management in acute pancreatitis

“…However, they were shown to reduce postoperative acute pain scores and decrease the use of other analgesics and antiemetics after gynecological surgery [19]. Antidepressants have a limited role in patients with acute pancreatitis because of the long time (weeks) to reach therapeutic efficacy [20,21].…”

Health professional perceptions of a pharmacist-led interprofessional chronic pain clinic

“…Finding the safest and most effective treatment options also often requires a laborious trial-and-error process. 6 The opioid crisis and the recent awareness that opioids often cause more harm than benefit in CNCP treatment has created a shift in practice guidelines, where opioids are no longer at the forefront of treatment. 3 , 7 , 8 CNCP is also frequently complicated by comorbid diagnoses of mental health conditions, such as depression, anxiety and personality disorders, which often require referrals to specialists and complicates pharmacotherapy, especially optimization of opioid pharmacotherapy.…”