Clinical Drug Investigation

, Volume 32, Supplement 1, pp 21–33 | Cite as

The Appropriate Treatment of Chronic Pain

  • Piercarlo Sarzi-PuttiniEmail author
  • Renato Vellucci
  • Stefano Maria Zuccaro
  • Paolo Cherubino
  • Roberto Labianca
  • Diego Fornasari
Review Article


Chronic pain is a common healthcare problem worldwide that ranks as a predominant reason for consulting a physician, yet effective management of chronic pain remains suboptimal, often resulting in unnecessary suffering and decreased quality of life, lost productivity and excessive healthcare costs. To overcome the challenges associated with the management of chronic pain, increased awareness and both patient and physician education are required. Improving physician knowledge of pain assessment and management guided by recommendations for a comprehensive, multifactorial, personalised treatment approach involving pharmacological and non-pharmacological approaches is key to achieving effective pain relief. Guidelines for the management of non-cancer and cancer pain recommend thorough patient assessment before individualized therapy based on the type and intensity of pain. The availability of mechanism-specific analgesics has facilitated improvements in the treatment of chronic non-cancer pain, which may be of neuropathic, muscle, inflammatory, mechanical/compressive or mixed origin. Stepwise escalation of analgesic therapy (paracetamol, non-steroidal anti-inflammatory drugs, mild to strong opioids) according to the World Health Organization’s three-step pain ladder remains the standard approach for the selection of treatment for chronic cancer pain, although there is now a greater awareness of the requirements for effective administration of opioids including dose titration, use of short versus long-acting opioids, opioid rotation, management of adverse effects, and ongoing monitoring. Selection of an effective, appropriate, personalized analgesic regimen for patients with chronic pain is achievable and is expected to enhance compliance, overall functioning and quality of life.


Chronic Pain Neuropathic Pain Tramadol Cancer Pain Hydromorphone 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Brennan F, Carr DB, Cousins M. Pain management: a fundamental human right. Anesth Analg 2007; 105(1): 205–21PubMedCrossRefGoogle Scholar
  2. 2.
    Lumley MA, Cohen JL, Borszcz GS, et al. Pain and emotion: a biopsychosocial review of recent research. J Clin Psychol 2011; 67(9): 942–68PubMedCrossRefGoogle Scholar
  3. 3.
    Crowley-Matoka M, Saha S, Dobscha SK, et al. Problems of quality and equity in pain management: exploring the role of biomedical culture. Pain Med 2009; 10(7): 1312–24PubMedCrossRefGoogle Scholar
  4. 4.
    Graziottin A, Gardner-Nix J, Stumpf M, et al. Opioids: How to Improve Compliance and Adherence. Pain Pract 2011; 11(6): 574–81PubMedCrossRefGoogle Scholar
  5. 5.
    Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Assessment and Management of Chronic Pain (fourth edition)2009: Available from:
  6. 6.
    Nicholson B. Responsible prescribing of opioids for the management of chronic pain. Drugs 2003; 63(1): 17–32PubMedCrossRefGoogle Scholar
  7. 7.
    Finnerup NB, Sindrup SH, Jensen TS. The evidence for pharmacological treatment of neuropathic pain. Pain 2010; 150(3): 573–81PubMedCrossRefGoogle Scholar
  8. 8.
    Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007; 132(3): 237–51PubMedCrossRefGoogle Scholar
  9. 9.
    Fornasari D. Pain mechanisms in patients with chronic pain. Clin Drug Investig 2012; 32 (Suppl. 1): 45–52CrossRefGoogle Scholar
  10. 10.
    Eisenberg E, McNicol E, Carr DB. Opioids for neuropathic pain. Cochrane Database Syst Rev 2006; 3: CD006146Google Scholar
  11. 11.
    Manchikanti L, Vallejo R, Manchikanti KN, et al. Effectiveness of long-term opioid therapy for chronic non-cancer pain. Pain Physician 2011; 14(2): E133–56PubMedGoogle Scholar
  12. 12.
    Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10(2): 113–30PubMedCrossRefGoogle Scholar
  13. 13.
    National Guideline Clearinghouse. Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians’ (ASIPP) guidelines. [Online] 2011; Available from:
  14. 14.
    National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for CNCP. [Online] 2010; Available from:
  15. 15.
    Ripamonti CI, Bandieri E, Roila F. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol 2011; 22 Suppl. 6: vi69–77PubMedCrossRefGoogle Scholar
  16. 16.
    World Health Organisation (WHO). WHO’s pain ladder2011: Available from:
  17. 17.
    National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Adult Cancer Pain version 1.2011. [Online] 2011; Available from:
  18. 18.
    Swarm R, Abernethy AP, Anghelescu DL, et al. Adult cancer pain. Journal of the National Comprehensive Cancer Network: JNCCN 2010; 8(9): 1046–86PubMedGoogle Scholar
  19. 19.
    Howard PA, Delafontaine P. Nonsteroidal anti-Inflammatory drugs and cardiovascular risk. J Am Coll Cardiol 2004; 43(4): 519–25PubMedCrossRefGoogle Scholar
  20. 20.
    Lewis SC, Langman MJ, Laporte JR, et al. Dose-response relationships between individual nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDs) and serious upper gastrointestinal bleeding: a meta-analysis based on individual patient data. Br J Clin Pharmacol 2002; 54(3): 320–6PubMedCrossRefGoogle Scholar
  21. 21.
    Pergolizzi J, Boger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract 2008; 8(4): 287–313PubMedCrossRefGoogle Scholar
  22. 22.
    McCarberg BH, Barkin RL. Long-acting opioids for chronic pain: pharmacotherapeutic opportunities to enhance compliance, quality of life, and analgesia. Am J Ther 2001; 8(3): 181–6PubMedCrossRefGoogle Scholar
  23. 23.
    American Pain Society. The use of opioids for the treatment of chronic pain: a consensus statement from American Academy of Pain Medicine and American Pain Society1996: Available from:
  24. 24.
    Glajchen M. Chronic pain: treatment barriers and strategies for clinical practice. J Am Board Fam Pract 2001; 14(3): 211–18PubMedGoogle Scholar
  25. 25.
    Stannard C, Johnson M. Chronic pain management-can we do better? An interview-based survey in primary care. Curr Med Res Opin 2003; 19(8): 703–6PubMedCrossRefGoogle Scholar
  26. 26.
    Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006; 10(4): 287–333PubMedCrossRefGoogle Scholar
  27. 27.
    Deandrea S, Montanari M, Moja L, et al. Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol 2008; 19(12): 1985–91PubMedCrossRefGoogle Scholar
  28. 28.
    Stubhaug A. European perspectives on pain and palliative care — Managing chronic osteoarthritic pain in primary care: an update. J Pain Palliat Care Pharmacother 2009; 23(4): 380–95CrossRefGoogle Scholar
  29. 29.
    Vellucci R, Sarzi-Puttini P, Zuccaro SM, et al. Barriers to pain management: Focus on opioid therapy Clin Drug Investig 2012; 32 (Suppl. 1): 3–10CrossRefGoogle Scholar
  30. 30.
    Schatman ME. The role of the health insurance industry in perpetuating suboptimal pain management. Pain Med 2011; 12(3): 415–26PubMedCrossRefGoogle Scholar
  31. 31.
    De las Cuevas C. Towards a clarification of terminology in medicine taking behavior: compliance, adherence and concordance are related although different terms with different uses. Curr Clin Pharmacol 2011; 6(2): 74–7PubMedCrossRefGoogle Scholar
  32. 32.
    Enting RH, Oldenmenger WH, Van Gool AR, et al. The effects of analgesic prescription and patient adherence on pain in a dutch outpatient cancer population. J Pain Symptom Manage 2007; 34(5): 523–31PubMedCrossRefGoogle Scholar
  33. 33.
    Miaskowski C, Dodd MJ, West C, et al. Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. J Clin Oncol 2001; 19(23): 4275–9PubMedGoogle Scholar
  34. 34.
    Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther 2001; 23(8): 1296–310PubMedCrossRefGoogle Scholar
  35. 35.
    Miller DA, Dinunzio JC, Williams 3rd RO. Advanced formulation design: improving drug therapies for the management of severe and chronic pain. Drug Dev Ind Pharm 2008; 34(2): 117–33PubMedCrossRefGoogle Scholar
  36. 36.
    Haynes RB, McDonald H, Garg AX, et al. Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev 2002; (2): CD000011Google Scholar
  37. 37.
    Upshur CC, Bacigalupe G, Luckmann R. “They don’t want anything to do with you”: patient views of primary care management of chronic pain. Pain Med 2010; 11(12): 1791–8PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2012

Authors and Affiliations

  • Piercarlo Sarzi-Puttini
    • 1
    Email author
  • Renato Vellucci
    • 2
  • Stefano Maria Zuccaro
    • 3
  • Paolo Cherubino
    • 4
  • Roberto Labianca
    • 5
  • Diego Fornasari
    • 6
  1. 1.Rheumatology UnitL. Sacco University HospitalMilanItaly
  2. 2.Palliative Care and Pain Therapy UnitUniversity Hospital of CareggiFlorenceItaly
  3. 3.Department of GeriatricsOspedale IsraeliticoRomeItaly
  4. 4.Department of Orthopaedics and TraumatologyUniversity of Insubria, Ospedale di Circolo-Fondazione MacchiVareseItaly
  5. 5.Oncology UnitOspedali Riuniti di BergamoBergamoItaly
  6. 6.Department of Pharmacology, School of MedicineUniversità degli Studi di Milano and CNR-Institute of NeuroscienceMilanItaly

Personalised recommendations