The impact of chronic pain—European patients’ perspective over 12 months

The authors of the one-year observational study of chronic pain patients [1] are to be commended on two counts. The first is to organize a multinational investigation to gain more perspective on the effects of chronic pain and its treatment in a short longitudinal study. The second is to use qualitative as well as quantitative methods since qualitative methods give richer information through narrative than can be obtained through the usual patient reported outcome (PRO) questionnaires. It is hoped that analysis of the qualitative data can be done to flesh out the dry statistical information from the PROs.

Although not as prominent in the final draft as in the original, there are some points that seem to standout and deserve comment. A simple observation is the prolonged discussion about constipation as if this were the major side effect of all pharmacological treatment for chronic non-malignant pain. Certainly it is prominent in opioid treatment but other more subtle side effects of long standing opioid treatment may be more important to quality of life issues than constipation. These have not been identified in the O’Brian/Breivik article but are reviewed in the literature in some detail [2]. Despite the fact that pain relief was not achieved by the majority of the patients in the study, the first point under “More needs to be done to provide patients with effective pain relief...” is again, opioid induced side effects although a minority were taking opioids.

The second point in the discussion section is the emphasis on the need for “referring patients to comprehensive multi-disciplinary pain clinics” as if this will solve all pain problems. There is some evidence to the contrary that shows that multidisciplinary pain clinics or specialist clinics using established guidelines for treatment do not have better outcomes than we see in this study. There is also some evidence that the multidisciplinary clinics are no more helpful than general practice clinics that use no other treatments than NSAIDs or over the counter medications. In a study called RELIEF [3] done through both specialty clinics and general practice clinics in Canada, patients were followed for one year with treatment as usual using a variety of PROs in an effort to validate those PROs in neuropathic pain. About 15% improved, about 13% were worse and the rest were unchanged. The statistics were the same in both specialty clinics and general practice clinics. It appeared that almost every known medication for neuropathic pain, singly or in combination, was used in specialty clinics. Those attending the general practice clinics received primarily paracetamol and NSAIDs, often over the counter.

In the Province of Quebec in Canada, all patients coming to tertiary care pain clinics are entered in a register that includes demographics, PROs and diagnostics. Follow-up data includes treatments, side effects, PROs for pain and quality of life and patient satisfaction. This is done through the Quebec Pain Research Network (QPRN). There is follow-up after treatment for a minimum of six months although the majority of patients stay in treatment for a year and that data is also available. After two years of registering patients, the QPRN report that the pain scores and quality of life have not improved although the patients are pleased with their treatments (unpublished data presented at the QPRN Winter Meeting, Quebec City, 2009).

There is some data indicating that intensive behaviorally oriented rehabilitation helps some patients but this expensive and time consuming treatment is not appropriate for the majority of patients with chronic pain. It is not offered by the majority of “multidisciplinary” pain clinics and if so, there are few details about what the programmes involve.

Yes, there is a problem as O’Brian and Breivik point out with education of physicians about pain as is highlighted in the article. Yes, there is a lack of true multidisciplinary pain clinics and access is limited and waiting lists are long [4]. However, what we really need is more knowledge about chronic pain mechanisms and about pain treatments that are actually effective and in what populations. More pain clinics with the same knowledge will only become a dumping ground for refractory patients but are not likely to decrease the burden of pain and disability related to chronic pain, given the information available on outcomes.

The pharmaceutical industry is spending billions of dollars yearly looking for new pain medications but have not put a single new medication for pain on the general market that is not a copy or a derivative of older medications for pain. Those older medications were often found by serendipity or come from folk medicine and are not the product of primary research. The gold standard currently for effectiveness for medications for pain is that 30% of the patients have 50% pain relief and that is just not sufficient improvement for many. What about the 70% with less or no pain relief?

What we really need is more studies to describe the treatment parameters and highlight the results of multidisciplinary care with careful descriptions of what “multidisciplinary” actually means for in many cases it refers to practitioners from more than one specialty or biomedical discipline. I suspect many of the clinics that advertise as being multidisciplinary are not and that the treatment in a true multidisciplinary setting is effective and appropriate for only a very small segment of chronic pain sufferers.

Yes, the situation for chronic pain patients is not good but there is currently little evidence that unlimited access to multidisciplinary care will improve this situation. I may be found wrong when good studies become available but I am waiting for the proof and remain skeptical. However, we must continue to do research, we must continue to teach and we must continue to try to improve access to specialized care for patients suffering from chronic, intractable pain as this article points out [1]. And the bottom line, as always, is that we must try to do the best we can for those unfortunate patients suffering from chronic pain.