Currently available treatments for chronic pain are unable to alleviate pain or restore functioning in the majority of patients. The findings of the second paper in The Lancet Series on pain highlight the large gaps in the evidence base and call for more research to assess the effectiveness of combinations of therapies to relieve chronic non-cancer pain, while ensuring that patients have realistic expectations about pain relief.
In this paper, Dennis C Turk and colleagues from the University of Washington, Seattle, USA review the evidence for the effectiveness of the most commonly used interventions to treat chronic pain over the past decade. They state that despite important advances in the understanding of the mechanisms underlying pain and a growing range of treatment options, overall effectiveness remains inconsistent and poor: "Of all treatment modalities reviewed [drugs, surgery, interventional, behavioural, rehabilitation, and alternative], the best evidence for pain reduction averages roughly 30% in about half of treated patients, and these pain reductions do not always occur with concurrent improvement in function."
Chronic pain is estimated to affect 20% of people worldwide. The costs of chronic pain are extremely high, with the USA spending over US$210 billion every year, while the estimate in the UK for back pain alone is $26 billion.
According to the authors, because current treatments by themselves provide only modest improvements in pain and physical and emotional functioning, future research should focus on the effectiveness of combining various treatments (combinations of several drugs, drugs with somatic treatments, and pharmacological and psychological treatments). To date few trials have assessed combinations of therapies, and there is little clear evidence for the beneficial effect of any particular combination.
Key recommendations include the need for a multi-faceted approach to treatment which involves the entire person, and for treatment effectiveness to include a measure of physical and emotional functioning, patient ratings of improvements, and adverse events, rather than just assessing pain severity. The authors urge: "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."
They conclude: "These results suggest that none of the most commonly prescribed treatment regimens are, by themselves, sufficient to eliminate pain and to have a major effect on physical and emotional function in most patients with chronic pain...There is a crucial need for assessment of combination treatments, identification of treatment response, and the assessment of the benefit of matching of treatments to patient characteristics."
Professor Dennis C Turk, University of Washington, Seattle, USA. T) +1 206 616 2626 E) firstname.lastname@example.org