New Perspectives in Acute Pain Management

The subject of this supplement is the safe and effective clinical management of acute pain. Pain and functional impairment resulting from pain are prevalent in primary-care practice as well as in postoperative treatment and in many of the most common disease states: primary and metastatic cancer, rheumatoid and osteoarthritis, unstable angina and acute coronary infarction, migraine headache, dysmenorrhea, musculoskeletal trauma, neuropathy, renal stones, and acute inflammation.

Contemporary pharmaceutical science has vastly expanded the alternatives for treating acute pain in several ways. First, the spectrum of non-opioid drugs has been broadened, particularly with the class of nonsteroidal anti-inflammatory drugs (NSAIDs). Second, with both opioids and non-opioids, new forms of administration have been devised: time-release, transdermal, epidural, and intrathecal dosing that make relief more consistent by leveling the pain/no-pain cycles. Third, entirely new technologies are under development, including (1) cell transplantation to increase expression of putative endogenous pain relievers such as endorphins and catecholamines, and (2) MDA receptor antagonists.

Clinicians have responded to this new arsenal by learning to correlate pain and functional impairment to treatment. The use of coanalgesics has expanded, as well as the use of adjuvant drugs for relief of side effects and supplementary psychosocial treatments. In addition to testing the efficacy and safety of individual drugs, clinical investigators have elucidated and tested comprehensive acute pain management guidelines for validity. With these developments, pain management has become a clinical specialty. The several papers in this supplement were designed and coordinated as a means of bringing to the individual practitioner the current knowledge of specialists in, and contributors to, this new field of medical practice.

Drs Donald Mehlisch and Thomas Schnitzer discuss the efficacy and clinical applications of analgesics in general, but with reference to specific applications (eg, soft-tissue injury, low back pain, and musculoskeletal pain) and to some surgical situations. New perspectives on the role of nonnarcotic analgesics postoperative pain are addressed in a report by Drs Michael Ashburn and Carla Rubingh. The use of nonnarcotic analgesics in short-term musculoskeletal pain is presented by Dr Joseph Markenson, who also describes the exciting developments and implications of cyclooxygenase enzymes. Dr Ronald Rapoport looks at the safety of NSAIDs.

The final two papers present different perspectives. Dr Jane Ballantyne looks at results of meta-analyses of acute and chronic pain trials of several nonnarcotic analgesics in order to create a comprehensive perspective for the practicing clinician, and Dr J. David Haddox provides guidance on current US law with respect to prescribing controlled substances for both hospitalized and ambulatory patients.

It is our hope that you will find the articles in this supplement not only educational, but also clinically relevant and practical.

Richard Payne, MD

Chief, Pain & Palliative Services
Department of Neurology
Memorial Sloan-Kettering Cancer Center
New York, NY