Palliation: Introduction

Abstract

Central pain (CP) remains one of the most ill-treated entities among chronic pain syndromes. No drug is substantially effective in a majority of patients, despite claims to the contrary by the pharma industry and regulatory agencies. Apparently, significant treatment effects reported in pharma-sponsored trials would have been much smaller or absent, and large high-quality trials have been conducted. Worse still, published papers are often marketing disguised as scientific papers [1, 2], and systematic reviews often “cause research waste” [3, 4]. Indeed, the vast majority (85%) of investment in health research is simply wasted [5]. Thus, it comes as no surprise that many treatments that are now considered first-line are associated with minimal relief (Cardenas and Jensen 2006). A large Swedish study found that, for mostly peripheral neuropathic pain, the most common first prescription is amitriptyline (40%) followed by pregabalin (22%) and gabapentin (19%): more than half of the patients discontinued treatment after 3 months and 60–70% at 6 months, with modestly better results with duloxetine and venlafaxine [6]. A prospective observational study found that standard guidelines as applied at academic centers are ineffective. Out of 80 CP patients (CPSP 11, SCI 47, and other 22; 53 patients available for analysis), only 11.3% (!) reached ≥30% relief at 2 years and 1 point reduction on the BPI/interference scale, and the vast majority experienced side effects from all classes of drugs [7].