Three reviews published June 25 in The Lancet take a tour across the clinical spectrum of pain and strategies for care of cancer pain; acute postoperative pain; and chronic, non-cancer pain. For basic researchers, the series provides an overview of what happens in the clinic. For bench scientists and clinicians, the review of chronic pain from Dennis Turk, Hilary Wilson, and Alex Cahana at the University of Washington in Seattle points out gaping holes in fundamental knowledge that must be filled to make effective management of long-term pain a reality.
In their piece, Turk and coauthors note that, despite advances in basic science, diagnostics, and therapy, current treatment strategies provide only limited relief from pain and little improvement in daily life for the majority of patients. What’s more, doctors cannot know which care plan is better, because evidence for most regimens is sorely lacking. In response, Turk and coauthors prescribe several priorities for research.
One area of need they identify is better testing of non-pharmacological treatments. “Sophisticated studies with creative placebo controls…are needed,” they write. More broadly, they say that, given the poor efficacy of most individual treatments, multimodality therapies need to be explored. “This conclusion is hardly surprising in view of the complexity of chronic pain,” they write. “Despite calls for the use of combination treatments, few studies have reported on the efficacy of combination therapy.”
The authors also emphasize that meaningful indicators of treatment response—including pain as well as physical and emotional functioning, patient satisfaction, and adverse events—must be used in clinical studies. “Unfortunately,” they write, “pain severity continues to be the primary outcome” used in most trials. In addition, they say more attention must be paid to patient selection—learning how to appropriately match treatments to patients. In sum, they write, “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 second review, by Russell Portenoy, Beth Israel Medical Center, New York, focuses on treatment of cancer pain. Portenoy highlights the integration of pain treatment into a palliative care framework, as well as the complex and varied pathophysiology underlying cancer pain. In the third piece, Christopher Wu and Srinivasa Raja, Johns Hopkins University and School of Medicine in Baltimore, Maryland, review treatment of acute postoperative pain. Wu and Raja note the frequent occurrence of persistent postsurgical pain, and explore current knowledge about risk factors. They call for better deployment of existing therapies and more research aimed at development of new ones.
An editorial accompanying the reviews underscores twin problems in pain management: the dearth of effective therapeutic strategies and the routine failure to follow guidelines in practice. The editorial refers to a recent report from Human Rights Watch, “Global State of Pain Treatment: Access to Palliative Care as a Human Right,” which describes poor availability of palliative care and pain-relieving drugs worldwide. Meanwhile, a new report from the United States National Academy of Sciences elaborates deficiencies in pain education, treatment, prevention and research in that country (see PRF news story). All together, these recent releases point to the critical need for research and the important role of clinicians who, along with their patients, ultimately form the front line in the fight against pain.