14
views
0
recommends
+1 Recommend
1 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Terminology of chronic pain: the need to “level the playing field”

      1 , 2

      Journal of Pain Research

      Dove Medical Press

      Read this article at

      ScienceOpenPublisherPMC
      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Discussion Pain medicine as a separate subspecialty is in its infancy, only fairly recently being recognized as such by the American Board of Medical Specialities.1 As it continues to find its way in the ever-changing world of medicine, terminology becomes an important consideration. Terms carry tremendous impact: for example, when a patient is told he or she has “cancer”, the impact emotionally will undoubtedly make further explanation difficult. To patients and their families, the word “cancer” has the effect of being hit with an emotional baseball bat. In the pain world, there was a recent, albeit failed, attempt to change the name of pain specialists to “algiatrists”.2 It was thought this would help define what such specialists did as opposed to other specialties. Accordingly, terminology matters, yet little attention has been paid to the terms we use to categorize and diagnose our patients. “Chronic cancer pain” and “chronic noncancer pain” are replete in the literature; however, the distinction here is actually obscure. A patient with pain from a cancer etiology has no different physiology than a patient with pain of noncancer etiologies. Much of the development in the literature defining these two different categories came from the move in the 1990s to change the way chronic pain in patients without cancer was treated.3 It was postulated that if opioids worked for pain in cancer patients, then we should accordingly use these same agents in those with pain not related to cancer. Further, it was posited that these patients were suffering, and opioids were one more tool to help ease their suffering. Those using the term “chronic noncancer pain” were in two camps: those who felt that opioids should be avoided in patients without cancer, and those who felt they were yet one more tool for the treatment of these patients.3,4 Interestingly, these claims are primarily philosophical, rather than medical or physiologic. As mentioned, pain mechanisms do not discriminate between cancer and noncancer pathophysiology. Patients with cancer or those without cancer have essentially identical pain-generating physiologies, and thus the same mechanisms for the development of their pain (eg, inflammatory pain in a cancer patient will be the same physiological process as in a noncancer patient). Further, cancer patients are living longer and their original pain generators become chronic pain in and of themselves, little different from patients without cancer. Frequently, the claim is that those without cancer should not have to undergo the side effects of opioids, and they should not have to take on the potential burden of iatrogenic addiction. Furthermore, they note that there are few data to support opioid use in these patients. Interestingly, the data on the use of opioids in cancer patients suffer from the same criticism, lack of long-term data, and lack of data demonstrating increased functionality.5,6 However, there is frequently the caveat that those with cancer should receive opioids, which represents a rather strange dichotomy. This line of reasoning can be interpreted as follows: We do not care if the patient with cancer suffers from side effects, fatal or otherwise from opioids, and/or develops a substance-use disorder. But we do care if a patient with chronic “noncancer” pain develops these problems. We do not care if patients with noncancer pain suffer; they are not “worth” the effort of adding opioids to their regimens. The purpose of this commentary is not to develop a foundation for increased use of opioids, nor are we suggesting that opioids be used more in patients without cancer. However, a thorough evaluation, followed by a clear delineation of the pain generators, will help define potential treatments, which may (or may not) include opioids. This should not be based on philosophical biases, or at least those biases should be stated openly up front as having no scientific foundation. Obviously, given other considerations associated with initiating chronic opioid therapy and the need for continued reevaluation, opioids may not be the best option. However, simply the label of “chronic noncancer pain” should not immediately place that patient in a category that eliminates certain potential therapies, eg, opioids. Therefore, we suggest that the terminology be changed to help us better to understand and treat all of our chronic pain patients who are suffering. Categorization into “cancer” and “noncancer” does not help us better understand mechanisms underlying pain or guide us to appropriate treatment strategies. Further, these categories are philosophical and neither scientific nor of clinical relevance. Perhaps a more prudent, less charged set of terms would indicate the origin and generator of the pain. Therefore, a patient with chest-wall pain from radiation due to breast cancer would be labeled “chronic pain of breast cancer radiation-treatment origin”. The patient with pain from an advanced spondylolisthesis would be diagnosed with “chronic pain of spondylolisthesis origin”. The goal here is to continue to be patient-focused, relieve their suffering (instead of contributing to it), and help improve their lives. Language, in and by itself, is obviously not a “cure” for pain. However, clinicians and society as a whole need to appreciate language’s potential to further stigmatize and marginalize all patients suffering from chronic pain, and accordingly we are obliged to work toward a more language-neutral system of pain classification.

          Related collections

          Most cited references 6

          • Record: found
          • Abstract: not found
          • Article: not found

          Potent opioids for chronic musculoskeletal pain: flying blind?

            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            A systematic review of randomized trials on the effectiveness of opioids for cancer pain.

            In all recommended guidelines put forth for the treatment of cancer pain, opioids continue to be an important part of a physician's armamentarium. Though opioids are used regularly for cancer pain, there is a paucity of literature proving efficacy for long-term use. Cancer is no longer considered a "terminal disease"; 50% to 65% of patients survive for at least 2 years, and there are about 12 million cancer survivors in the United States. There is a concern about side effects, tolerance, abuse and addiction with long-term opioid use and a need to evaluate the effectiveness of opioids for cancer pain. The objective of this systematic review was to look at the effectiveness of opioids for cancer pain. A systematic review of randomized trials of opioids for cancer pain. A comprehensive review of the current literature for randomized controlled trials (RCTs) of opioids for cancer pain was done. The literature search was done using PubMed, EMBASE, Cochrane library, clinical trials, national clearing house, Web of Science, previous narrative systematic reviews, and cross references. The studies were assessed using the modified Cochrane and Jadad criteria. Analysis of evidence was done utilizing the modified quality of evidence developed by United States Preventive Services Task Force (USPSTF). Pain relief was the primary outcome measure. Secondary outcome measures are quality of life (QoL) and side effects including tolerance and addiction. The level of evidence for pain relief based on the USPSTF criteria was fair for transdermal fentanyl and poor for morphine, tramadol, oxycodone, methadone, and codeine. Randomized trials in a cancer setting are difficult to perform and justify. There is a paucity of long-term trials and this review included a follow-up period of only 4 weeks. This systematic review of RCTs of opioids for cancer pain showed fair evidence for the efficacy of transdermal fentanyl and poor evidence for morphine, tramadol, oxycodone, methadone, and codeine.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              Chronic opioid therapy in nonmalignant pain.

               R Portenoy (1990)
              This review draws on data obtained in the cancer pain, nonmalignant pain, and addict populations to examine critically the major issues raised by the use of chronic opioid therapy in nonmalignant pain. The available evidence suggests that there is probably a selected subpopulation of patients with chronic nonmalignant pain who may obtain sustained partial analgesia without the development of toxicity or the psychologic and behavioral characteristics of addiction. Future discussions of this approach must adequately define the terminology of addiction and strive to distinguish medical considerations from the societal and regulatory influences that may affect prescribing behavior. Those who treat patients with chronic pain must actively participate in these discussions lest decisions with enormous impact on patient care be made solely by those whose primary responsibility is the elimination of substance abuse.
                Bookmark

                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2016
                27 January 2016
                : 9
                : 23-24
                Affiliations
                [1 ]Center for Bioethics, Pain Management and Medicine, St Louis, MO, USA
                [2 ]US Pain Foundation, Middletown, CT, USA
                Author notes
                Correspondence: John F Peppin, Center for Bioethics, Pain Management and Medicine, 8013 Presidio Court, University City, St Louis, MO 63130, USA, Email johnpeppin@ 123456msn.com
                Article
                jpr-9-023
                10.2147/JPR.S99629
                4734783
                26869809
                © 2016 Peppin and Schatman. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Commentary

                Anesthesiology & Pain management

                Comments

                Comment on this article