Session held on Sunday 3 June
In this session reviewing top publications on pain, acute pain was covered by Professor Marco A.E. Marcus, Chairman of the Department of Anesthesiology and SICU, Hamad Medical Corporation, and Professor at both Weill Cornell, Qatar and University Hospital Maastricht, the Netherlands.
“When something pleasant is happening to us, we never wonder ‘why me?’. Yet when something unpleasant like a disease or chronic condition, is happening to us, one often wonders: ‘why me?’,” said Professor Marcus.
He referred to an editorial about chronic post-surgical pain (CPSP) by Dr Patricia Lavand’homme, written for the British Pain Society, that posed the question: “why me?” — a question it is impossible to answer based on our current knowledge.
Predictors might help in preventing the development of a so-far therapy-resistant condition such as chronic pain (Beloeil et al., the European Journal of Anesthesiology). Efforts are ongoing to develop and design algorithms including predictors, to be able to identify those with an increased risk to develop chronic pain. Interference in a process, which so far defies our inventiveness, is lurking on the horizon as a real possibility (Weinrib et al. in the British Journal of Pain).
Professor Marcus concluded: “The main problem remains that the key to the process of pain becoming chronic is located centrally in our brain (Chapman et al.). Our focus should be there as well, to identify the basic mechanism of the development of chronic pain and to be able to design target specific drugs (Wsi Hsin Chen in Pain). It will take time and effort to answer the question: why me?”
Chronic pain was covered by Dr Marc Suter, University Hospital Vaudois, Lausanne, Switzerland. “For this year’s hot topic on chronic pain I decided there would not be a topic on the epidemic of opioids or neuropathic pain guidelines, but on some consequences of these topics of previous years, namely the potential over/inadequate use of gabapentinoid, for which increased prescription might be cause of concern.”(Goodman CW, NEJM).
Tapering of opioids gives good results as published (Frank JW, Ann Intern Med.2017) with improvement on pain, function and quality of life. Uncertainty has been thrown on the efficacy of the older drugs gabapentinoid on low back pain (Shanthanna H, Plos MED) and paracetamol on hip and knee arthritis pain (Da Costa BR, Lancet).
New treatments are coming with new drugs targeting the sodium channel Nav1.7, preferentially expressed on nociceptors, for trigeminal neuralgia (Zakrzewska JM, Lancet Neurol), anti-CGRP drugs for migraine, or also biased opioid-agonists (Goodman CW, NEJM): these medications have all successfully passed clinical trials.
“For interventional pain therapy the biggest stir was probably caused by the MINT trial (Juch JNS JAMA), advocating against radiofrequency denervation of facet joints, but very disputed for methodological issues in design and in the way the interventions were performed,” says Dr Suter. “While waiting for this issue to be clarified, we can still prescribe yoga (Saper RB Ann Intern Med), which performed no worse than the first recommended treatment currently: physical therapy.”
He concludes: “With my own interest in neuroinflammation, this topic could not be forgotten with a step toward a mechanism based approach in a PETscan study using a glial marker, which could predict which patients would react preferentially to a steroid epidural injection for sciatica (Albrecht DS, Pain).”