Improving pain management: are we jumping from the frying pan into the fire?

Henrik Kehlet, MD, PhD† The review article by Brennan, Carr, and Cousins (1) is a laudable effort to discuss the ethical, political, cultural, and legal challenges involved in trying to improve the management of both acute and chronic pain. Unfortunately, this largely philosophical review fails to provide convincing scientific arguments to support the authors’ strongly held beliefs that many physicians fail to provide adequate pain relief because of a lack of concern and/or because of misconceptions regarding the use of analgesics in the management of pain (1–3). Although there is a clear need for improved techniques for controlling acute and chronic pain, we have serious concerns about the authors’ seemingly narrow focus on the alleged under-use of opioid analgesics and their suggestion that more liberal use of opioids can solve the problem. We would strongly argue for a more balanced view when considering approaches to improving acute and chronic pain management. Brennan et al. (1) are appropriately critical of the myths perpetuated by misinformed physicians. However, in characterizing individuals who advocate against more liberal use of opioid (narcotic) analgesics as “opioidphobic and/or opioignorant,” they demonstrate a disconcerting lack of insight into the recent literature relating to the frequent adverse effects associated with the use of opioid analgesics in the management of acute and chronic pain. Not only are opioid-related adverse drug events common in hospitalized patients, they increase the length of stay and total hospital cost (4,5). In reviewing the critical outcomes related to the use of opioids in the management of chronic noncancer pain, Eriksen et al. (6) recently concluded that long-term use of these compounds in the treatment of noncancer pain failed to improve the patients pain relief, quality of life or functional capacity. A recent study by Chu et al. (7) suggested that opioid tolerance and hyperalgesia develop within one month of initiating therapy with oral morphine in patients with chronic pain. Even short-term use of potent opioid compounds for acute pain can produce clinically significant hyperalgesia (8–10). Brennan et al. (1) state that the “under-treatment of pain is a poor medical practice that results in many adverse effects” and “is an abrogation of a fundamental human right. ” Yet, they fail to provide scientific evidence from the peer-reviewed medical literature to support many of their statements regarding the alleged benefits of more aggressive approaches to acute and chronic pain management for patients, their families and society. Interestingly, in a recent issue of Anesthesia & Analgesia, Liu and Wu (11) performed a systematic review of the pain literature and concluded that evidence supporting improved outcomes due to better postoperative pain management is lacking. Although the methodology used by these investigators has been questioned (12), we would also strongly disagree with the conclusions of Brennan et al. (1) regarding the purported benefits of liberalizing the use of opioid analgesics in the management of pain. In fact, some clinical studies have suggested that use of large doses of opioid analgesics may contribute to increased morbidity and mortality in the acute care setting (13). Brennan et al. (1) have also completely From the *Department of Anesthesiology and Pain Management, University of TX Southwestern Medical Center at Dallas, Texas, †Section for Surgical Pathophysiology, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark. Accepted for publication April 10, 2007. Supported by Endowment funds from the Margaret Milam McDermott Distinguished Chair of Anesthesiology and the White Mountain Institute (to P.F.W.). Address correspondence and reprint requests to Paul F. White, MD, PhD, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9068. Address e-mail to paul.white@utsouthwestern.edu. Copyright © 2007 International Anesthesia Research Society DOI: 10.1213/01.ane. 0000268392.05157. a8