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ISSUE NO 4 11 NEWS & REVIEWS The prevalence, correlates and treatment of pain in the European Union Langley PC CMRO, 2011, 27:463–480 The internet-based 2008 National Health and Wellness Survey (NHWS) surveyed 53,524 persons in the UK, France, Spain, Germany and Italy to report on the prevalence, severity and social consequences of pain. Extrapolating the results to the overall population of the 5 EU countries, the presence of severe, moderate, and mild pain within the last month was reported by 11.2, 29.4, and 9.0 million persons, respectively. The prevalence of daily pain was 8.85% in the total pain population. The effect of pain on normal functioning was shown by impact of severe and frequent pain on the HRQoL (Health Related Quality of Live).This was most noticeable on the physical component score (PCS) of the questionnaire, which was reduced by approximately 40% compared to the no pain population. Pain also impacted on workplace productivity and healthcare resource utilization; labour force participation in the no pain group was 64.46% compared to 44.67% in the severe pain group. Those experiencing severe pain had a substantially higher number of health provider visits (11.83 vs. 4.39), emergency room visits (0.50 vs. 0.18), and hospitalisations (0.59 vs. 0.14). The reported prevalence of pain in these 5 countries represents a substantial overall burden not only to individuals, but also to employers, healthcare systems and society in general. Opioids: a two-faced Janus Ahlbeck K CMRO, 2011, 27:439-448 Although classical opioids are a mainstay for the treatment of long- term, severe pain, their clinical utility is compromised by the required balance between efficacy and side effects. Adverse effects, both peripheral and central, are responsible for poor quality of life and low compliance rates, resulting in inadequate pain relief. Tolerance development, and dependency are further problems which affect the long-term use of classical opioids, particularly in complex pain conditions such as low back pain, where treatment often involves targeting both the nociceptive and neuropathic pain systems. Recent treatment strategies include co-administration of opioids with non-opioid analgesics to reduce side effects and/or risk of dependency. For example, controlled release oxycodone has been used in combination with pregabalin to treat patients with neuropathic pain. Novel delivery mechanisms such as transdermal preparations have also been used to improve tolerability of classical opioids. Under development are non-opioid agents that reduce side effects and enhance analgesia such as glial cell modulators, and novel agents with combined opioidergic and monoaminergic activity within the same molecule (MOR-NRI compounds). However, despite these recent advances, there have been very few completely novel drug developments and there remains a continuing need for innovative therapeutic strategies for the treatment of long-term pain. Pharmacotherapy of low back pain: targeting nociceptive and neuropathic pain components Morlion B CMRO, 2011, 27:11–33 Since chronic low back pain (LBP) is classified as a mixed pain syndrome, pharmacological treatment needs to be focused on both nociceptive and neuropathic components. Although opioids target both nociceptive and to a lesser extent neuropathic pain and may be effective in chronic LBP, many patients require higher doses or combination treatment. Paracetamol, NSAIDs and COX-2 inhibitors target the nociceptive component of chronic LBP. Antidepressants target the neuropathic component of chronic LBP; however, conflicting efficacy results have been reported. The topical preparation lidocaine 5% plaster, indicated in post-herpetic neuralgia, is effective in localized neuropathic pain in patients with chronic LBP. Combining drugs with different mechanisms of action (e.g. an agent with µ-receptor activity plus an agent of a different class) represents a rational approach to management of chronic pain with both nociceptive and neuropathic components. Pregabalin is ineffective as monotherapy for chronic LBP but is effective when combined with celecoxib or opioids. However, the utility of free combinations of analgesics is limited by the difficulty of maintaining the dose ratio within the desired therapeutic range, and the possibility of poor adherence. The design of novel strong-acting analgesics with more than one mechanism of action within the same molecule can potentially overcome these limitations. NEW PUBLICATIONS – IN FOCUS