Friday, June 24, 2011

Common Treatments Fail to Relieve Chronic Pain

Pain-Pourri According to recent commentary, a regrettable reality is that currently available treatments for chronic noncancer pain are unable to alleviate pain or restore functioning in a majority of patients. Those observations, from a new series on pain appearing in The Lancet, highlight large gaps in the evidence base and call for more research to assess the effectiveness of combination therapies to relieve chronic pain, while ensuring that patients have realistic expectations about pain relief.

Dennis C. Turk and colleagues from the University of Washington, Seattle, observe that 20% of all persons worldwide have some degree of chronic pain, imposing a total economic burden of $210 billion in the United State alone each year [Turk et al. 2011]. They briefly review evidence for the effectiveness of the most commonly used modalities to treat chronic pain during the past decade, covering a broad spectrum: pharmacologic, surgical, interventional, physical rehabilitation, psychological, and CAM (complementary and alternative medicine).

The authors conclude that, despite important advances in understandings of the mechanisms underlying pain and a growing range of treatment options, overall effectiveness remains inconsistent and poor. Even when statistically significant effect sizes are reported in research, “the clinical meaningfulness of the outcomes is not always clear,” they state. “Of all treatment modalities reviewed, the best evidence for pain reduction averages roughly 30% in about half of treated patients, and these pain reductions do not always occur with concurrent improvement in function.”

According to the authors, because current treatments by themselves provide only modest improvements in pain and physical and emotional functioning, future research should focus on the effectiveness of combining various treatments; such as, combinations of several drugs, combining drugs with physical treatments, and pharmacological combined with psychological treatments. To date few trials have assessed combinations of therapies, and there is little clear evidence as yet for the beneficial effect of any particular combination.

For the foreseeable future, they note, “people with chronic pain will continue to live with some level of pain irrespective of the treatment or treatments they receive.” Therefore, chronic pain management should include a “dialogue with the patient about realistic expectations of pain relief, and bring focus to improvement of function.”

Key recommendations from the authors stress the need for a multifaceted approach to pain treatment that involves the whole person, and for treatment effectiveness to include measures of physical and emotional functioning, patient ratings of improvements, and adverse events, rather than just assessing pain duration, frequency, and/or severity. The authors urge: “A great need exists for research that goes beyond asking the questions of whether a particular treatment is effective, to addressing what treatment is effective, for which patients, on what outcomes, under what circumstances, and at what cost.”

A companion editorial to The Lancet series on pain reminds healthcare providers of their ongoing obligation to manage pain more effectively and states the following…

In 1931, physician and philosopher Albert Schweitzer said: “We must all die. But if I can save [patients] from days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.” To help eliminate or mitigate an individual’s pain is a privilege that clinicians must neither forget nor neglect.

REFERENCE: Turk DC, Wilson HD, Cahana A. Treatment of Chronic Non-Cancer Pain. The Lancet. 2011(Jun 25);377:2226-2235 [abstract here].