Supporting management of chronic pain in primary care

Chronic pain, whether it is cancer related or otherwise, is often considered as a chronic disease, with several aetiologies at play. The treatment strategy requires a multi-faceted approach, which may be used in combination depending on patient choice, circumstances and underlying disease.

Medication often forms a major part of the therapeutic regimen. Chronic pain has a multifactorial aetiology and is exacerbated by depression and anxiety. Conversely, a positive affect can reduce the perception of chronic pain. As such, mood and personal circumstances have a major influence over the management strategy of these patients.

UK guidelines on the management of pain in adults with cancer and the UK guidelines on opiates in palliative care follow the principles of the WHO analgesic ladder.

Factors influencing choice of opiate include local and national guidelines, patient wishes, underlying disease process, severity and nature of the pain, current drug regimen, individual history of allergies, opiate toxicity and side-effects, ability to swallow and acquisition cost.

UK guidelines on cancer and palliative care promote the use of sustained release oral morphine preparations as the initial strong opiate of choice for maintenance treatment and the transdermal route as the preferred non-oral route of administration in patients with stable opiate requirements.

Transdermal opiates offer several advantages over oral or subcutaneous modes of delivery. Aside from offering patients further choice, they provide a valuable alternative for people who are unable to swallow or absorb adequately.
Patients with advanced cancer, severe vomiting or gastrointestinal obstruction are examples where transdermal patches are used in cancer palliation on a daily basis.

There are circumstances where the delivery of a drug through a transdermal patch is desirable, and used in the right way, this approach can offer a patient good quality of life.

G Mohan.