Clinical Drug Investigation

, Volume 32, Supplement 1, pp 35–44

The Management of Chronic Pain in Important Patient Subgroups

  • Paolo Cherubino
  • Piercarlo Sarzi-Puttini
  • Stefano Maria Zuccaro
  • Roberto Labianca
Review Article


Chronic pain is a major healthcare issue in Europe and globally, and inadequate or undertreated pain significantly reduces the ability of many patients to participate in ordinary daily activities, adversely affects their employment status and contributes to a substantial rate of depression and anxiety in patients with chronic pain. There is a broad distinction of chronic pain into chronic non-cancer pain and chronic cancer pain, and important subgroups of these include patients with rheumatic and/or orthopaedic diseases, pain syndromes caused by cancer itself and caused by cancer treatment. Despite comprising the majority of non-cancer pain in Europe, chronic non-cancer pain associated with rheumatic diseases and/or orthopaedic conditions is often inadequately managed. Although paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) play a continuing role in the treatment of chronic rheumatic diseases, accumulating evidence of potential toxicity with both traditional non-selective NSAIDs and selective cyclooxygenase 2 inhibitors has prompted a reassessment of their use. This has particular resonance for the elderly, who are more likely to have significant pain issues than younger patients and are at high risk of NSAID-related adverse events. The use of mild opioids, such as codeine and tramadol, and strong opioids, such as morphine, hydromorphone and oxycodone, may be appropriate where paracetamol and other non-opioid analgesics are ineffective in chronic non-cancer pain. Cancer pain, either related to the underlying disease or caused by cancer treatment, is also a common cause of chronic pain in the elderly. An understanding of individual needs is essential in providing adequate pain relief, which is a central goal of care in all patients with chronic pain


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    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
  2. 2.
    Reid KJ, Harker J, Bala MM, et al. Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact. Curr Med Res Opin 2011; 27(2): 449–62PubMedCrossRefGoogle Scholar
  3. 3.
    Kumar N. WHO Normative Guidelines on Pain Management. Geneva: World Health Organization, 2007 JuneGoogle Scholar
  4. 4.
    Pogatzki-Zahn EM, Englbrecht JS, Schug SA. Acute pain management in patients with fibromyalgia and other diffuse chronic pain syndromes. Curr Opin Anaesthesiol 2009; 22(5): 627–33PubMedCrossRefGoogle Scholar
  5. 5.
    Vellucci R. Heterogeneity of chromic pain. Clin Drug Investig 2012; 32 (Suppl. 1): 3–10CrossRefGoogle Scholar
  6. 6.
    Fornasari D. Pain mechanisms in patients with chronic pain. Clin Drug Investig 2012; 32 (Suppl. 1): 45–52CrossRefGoogle Scholar
  7. 7.
    Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Assessment and Management of Chronic Pain (fourth edition)2009: Available from:
  8. 8.
    Pendleton A, Arden N, Dougados M, et al. EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2000; 59(12): 936–44PubMedCrossRefGoogle Scholar
  9. 9.
    Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis 2008; 67(4): 536–41PubMedCrossRefGoogle Scholar
  10. 10.
    Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010; 62(5): 600–10CrossRefGoogle Scholar
  11. 11.
    American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002; 46(2): 328–346CrossRefGoogle Scholar
  12. 12.
    National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults 2008: Available from:
  13. 13.
    National Collaborating Centre for Chronic Conditions. Rheumatoid arthritis: national clinical guideline for management and treatment in adults2009: Available from:
  14. 14.
    Herndon CM, Hutchison RW, Berdine HJ, et al. Management of chronic nonmalignant pain with nonsteroidal antiinflammatory drugs. Joint opinion statement of the Ambulatory Care, Cardiology, and Pain and Palliative Care Practice and Research Networks of the American College of Clinical Pharmacy. Pharmacotherapy 2008; 28(6): 788–805PubMedCrossRefGoogle Scholar
  15. 15.
    Combe B, Landewe R, Lukas C, et al. EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007; 66(1): 34–45PubMedCrossRefGoogle Scholar
  16. 16.
    Schnitzer TJ. Update on guidelines for the treatment of chronic musculoskeletal pain. Clin Rheumatol 2006; 25 Suppl. 1: S22–9PubMedCrossRefGoogle Scholar
  17. 17.
    Zhang W, Doherty M, Arden N, et al. EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2005; 64(5): 669–81PubMedCrossRefGoogle Scholar
  18. 18.
    Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007; 66(3): 377–88PubMedCrossRefGoogle Scholar
  19. 19.
    Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16(2): 137–62PubMedCrossRefGoogle Scholar
  20. 20.
    Ng SC, Chan FK. NSAID-induced gastrointestinal and cardiovascular injury. Curr Opin Gastroenterol 2010; 26(6): 611–17PubMedCrossRefGoogle Scholar
  21. 21.
    Garcia Rodriguez LA, Gonzalez-Perez A, Bueno H, et al. NSAID use selectively increases the risk of non-fatal myocardial infarction: a systematic review of randomised trials and observational studies. PLoS One 2011; 6(2): e16780PubMedCrossRefGoogle Scholar
  22. 22.
    Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ 2011; 342: c7086PubMedCrossRefGoogle Scholar
  23. 23.
    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
  24. 24.
    Whittle SL, Richards BL, Husni E, et al. Opioid therapy for treating rheumatoid arthritis pain. Cochrane Database Syst Rev 2011; 11: CD003113Google Scholar
  25. 25.
    Lang LJ, Pierer M, Stein C, et al. Opioids in rheumatic diseases. Ann N Y Acad Sci 2010; 1193: 111–16PubMedCrossRefGoogle Scholar
  26. 26.
    Podichetty VK, Mazanec DJ, Biscup RS. Chronic nonmalignant musculoskeletal pain in older adults: clinical issues and opioid intervention. Postgrad Med J 2003; 79(937): 627–33PubMedCrossRefGoogle Scholar
  27. 27.
    Furlan AD, Sandoval JA, Mailis-Gagnon A, et al. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ 2006; 174(11): 1589–94PubMedCrossRefGoogle Scholar
  28. 28.
    Nicholson B. Responsible prescribing of opioids for the management of chronic pain. Drugs 2003; 63(1): 17–32PubMedCrossRefGoogle Scholar
  29. 29.
    Eisenberg E, McNicol ED, Carr DB. Efficacy and safety of opioid agonists in the treatment of neuropathic pain of nonmalignant origin: systematic review and meta-analysis of randomized controlled trials. JAMA 2005; 293(24): 3043–52PubMedCrossRefGoogle Scholar
  30. 30.
    Lawson K. Treatment options and patient perspectives in the management of fibromyalgia: future trends. Neuropsychiatr Dis Treat 2008; 4(6): 1059–71PubMedCrossRefGoogle Scholar
  31. 31.
    Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA 2004; 292(19): 2388–95PubMedCrossRefGoogle Scholar
  32. 32.
    Sommer C. Fibromyalgia: A Clinical Update. Pain: Clinical Updates, 2010; XVIII(4): 1–4Google Scholar
  33. 33.
    Schneider P, Farahati J, Reiners C. Radiosynovectomy in rheumatology, orthopedics, and hemophilia. J Nucl Med 2005; 46 Suppl. 1: 48S–54SPubMedGoogle Scholar
  34. 34.
    American Geriatric Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009; 57(8): 1331–46CrossRefGoogle Scholar
  35. 35.
    Colson J, Koyyalagunta D, Falco FJ, et al. A systematic review of observational studies on the effectiveness of opioid therapy for cancer pain. Pain Physician 2011; 14(2): E85–102PubMedGoogle Scholar
  36. 36.
    National Institutes of Health. NIH State-of-the-Science Statement on symptom management in cancer: pain, depression, and fatigue. NIH Consens State Sci Statements 2002; 19(4): 1–29Google Scholar
  37. 37.
    Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med 2001; 17(3): 457–78, viPubMedCrossRefGoogle Scholar
  38. 38.
    World Health Organization. National Cancer Control Programmes: Policies and managerial guidelines. 2nd Edition 2002: Available from:
  39. 39.
    Breivik H, Cherny N, Collett B, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Ann Oncol 2009; 20(8): 1420–33PubMedCrossRefGoogle Scholar
  40. 40.
    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
  41. 41.
    Raphael J, Ahmedzai S, Hester J, et al. Cancer pain: part 1: Pathophysiology; oncological, pharmacological, and psychological treatments: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners. Pain Med 2010; 11(5): 742–64PubMedCrossRefGoogle Scholar
  42. 42.
    National Comprehensive Cancer Network. NCCN Practice Guidelines in Oncology: Adult Cancer Pain, Version I. [Online] 2011; Available from:
  43. 43.
    Regan JM, Peng P. Neurophysiology of cancer pain. Cancer Control 2000; 7(2): 111–19PubMedGoogle Scholar
  44. 44.
    World Health Organization. Cancer Control: Knowledge into Action, WHO Guide for Effective Programmes-Palliative Care2007: Available from:
  45. 45.
    Brennan F. Palliative care as an international human right. J Pain Symptom Manage 2007; 33(5): 494–9PubMedCrossRefGoogle Scholar
  46. 46.
    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
  47. 47.
    Ripamonti CI, Bandieri E, Roila F. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol 2011; 22 Suppl. 6: vi69–77PubMedCrossRefGoogle Scholar
  48. 48.
    Smith HS. Opioid metabolism. Mayo Clinic proceedings Mayo Clinic 2009; 84(7): 613–24PubMedGoogle Scholar
  49. 49.
    Roque IFM, Martinez-Zapata MJ, Scott-Brown M, et al. Radioisotopes for metastatic bone pain. Cochrane Database Syst Rev 2011; (7): CD003347Google Scholar
  50. 50.
    AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002; 50 (6 Suppl.): S205–24Google Scholar
  51. 51.
    Ospina M, Harstall C. Prevalence of chronic pain: an overview. Edmonton, Alberta: Alberta Heritage Foundation for Medical Research, 2002Google Scholar
  52. 52.
    Monti DA, Kunkel EJ. Management of chronic pain among elderly patients. Psychiatr Serv 1998; 49(12): 1537–9PubMedGoogle Scholar
  53. 53.
    Forde G. Adjuvant analgesics for the treatment of neuropathic pain: evaluating efficacy and safety profiles. J Fam Pract 2007; 56 (2 Suppl Pain): 3–12PubMedGoogle Scholar
  54. 54.
    Vellucci R, Sarzi-Puttini P, Zuccaro SD, et al. Barriers to pain management: Focus on Opioid Theory Clin Drug Investig 2012; 32 (Suppl. 1): 11–9Google Scholar
  55. 55.
    Herr K. Pain assessment strategies in older patients. J Pain 2011; 12 (3 Suppl 1): S3–S13PubMedCrossRefGoogle Scholar
  56. 56.
    Barkin RL, Beckerman M, Blum SL, et al. Should non-steroidal anti-inflammatory drugs (NSAIDs) be prescribed to the older adult? Drugs Aging 2010; 27(10): 775–89PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2012

Authors and Affiliations

  • Paolo Cherubino
    • 1
  • Piercarlo Sarzi-Puttini
    • 2
  • Stefano Maria Zuccaro
    • 3
  • Roberto Labianca
    • 4
  1. 1.Department of Orthopaedics and TraumatologyUniversity of Insubria, Ospedale di Circolo-Fondazione MacchiVareseItaly
  2. 2.Rheumatology UnitL. Sacco University HospitalMilanItaly
  3. 3.Department of GeriatricsOspedale IsraeliticoRomeItaly
  4. 4.Department of Oncology and HaematologyOspedali RiunitiBergamoItaly

Personalised recommendations