The study and the struggle: pain management in education and clinical practice.

The World Health Organization, national health authorities, and scientific societies have promoted and sustained numerous campaigns for pain management. As a result, attention to pain management and its quality of treatment seem to have improved nearly everywhere. Internal Medicine is a clinical setting that includes a great variety of pathologies, and pain control represents a frequent and emerging issue for patients and doctors in this field. Despite concrete progress, challenges still remain in terms of awareness, patient evaluation and treatment. The FADOI-Domino Study reported by Civardi et al. (1) clearly points out emerging critical issues in the management of chronic pain in Internal Medicine wards. The number of wards and patients involved in this study were adequate for the objectives of the study. The prevalence of pain reflects that reported in the literature. The patient cohort mostly included elderly people suffering from frailty, multimorbidity and probably different degrees of disability and polytherapy; osteoarticular and cancer pain represented 60% of all pain types in the study. This paper first addressed the pivotal roles of awareness and measurement. The major challenge is to lead medical and nursing personnel to focus on the observation, measurement and analysis of pain (2). Patients with chronic pain present with great complexity, and actual evaluation seems to be farfrom adequate in general practice. Even though sensitivity to the ‘Fifth Vital Sign’ has improved and is often scheduled inpatient evaluation, pain assessment is still not a frequent practice, and it still encompasses relatively few patients, as Civardi et al. demonstrated. The educational intervention proposed in this paper seeks to increase the percentage of patients who undergo appropriate assessment. Chronic pain management presents several specific difficulties because of the duration of the disorder. Some researchers invoke neuroplasticity and central sensitisation to explain the persistence of pain beyond nociception; the peripheral modulation of receptors also seems to be important (3). Psychological involvement, communication difficulties, and depression are always involved in pain perception, and inadequate pain control can cause a ‘spiral’ of disability and depression. For these reasons (the pathophysiology of chronic pain, psychological involvement and depression), several concerns have been raised regarding the use of instruments that adequately measure pain; numerical scales sometimes seem to over- or misestimate pain intensity (4,5). Perhaps new tools should be developed and/or existing tools improved to evaluate patient satisfaction, moods and whether they wish to receive more drugs for pain relief. Improving the treatment of pain is another issue addressed by this investigation. The FADOI-DOMINO Study underscored the need for education in this field and proposed a standardised intervention to improve pain management. Increased efficacy was demonstrated in terms of patient pain assessment, monitoring during hospitalisation and better treatment with strong opioids. These results are important and should stimulate interest in proposing educational programs. In addition, the chronic aspect of pain management requires a multilevel approach. Patient satisfaction and their wish to reach a different level of pain control should be stressed; the extended use of strong opioids in monotherapy should be avoided when possible (6). Adjuvant therapy should be enhanced, particularly when the patient suffers from anxiety and depression, suggesting that acupuncture and psychological approaches should be considered (3). Communication with patients remains relevant, and the collection of information about patient mood is important as well. Questions about patient satisfaction and their desired level of pain control, balanced with collateral drugs are strongly suggested. Chronic pain requires specific medical skills, as highlighted by the FADOI-DOMINO study, but they are not enough; human and empathic relationships are ultimately indispensable. In short, the more you ask your patient, the better their pain relief.