Expert Panel Consensus Recommendations for the Pharmacological

The Journal of International Medical Research2011; 39: 1123 – 1141 [first published online as 39(4) 8]

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Expert Panel ConsensusRecommendations for the

Pharmacological Treatment of Acute Painin the Middle East Region

AE AYAD1, N GHALY2, R RAGAB3, S MAJEED4, H NASSAR5, A AL JALABI6, A AL SHOAIBI7,S EL NOOR8, A SALTI9, J COSTANDI10,11, AZ ZEIDAN3 AND SA SCHUG12,13

1Department of Anaesthesiology and Pain, Cairo University, Cairo, Egypt; 2Department ofOrthopaedics, Ain-shams University, Cairo, Egypt; 3Department of Anaesthesiology andSurgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt;

4Department of Orthopaedic Surgery, Arab Medical Centre and Al Khalidi MedicalCentre, Amman, Jordan; 5Bahman Hospital, Beirut, Lebanon; 6Departments of

Anaesthesia, Pain Management and Intensive Care, Hamad Medical Corporation andWeill Cornell Medical College, Doha, Qatar; 7Department of Anaesthesia, King AbdulAziz Medical City, Riyadh, Saudi Arabia; 8Department of Orthopaedics, Security ForcesHospital, Riyadh, Saudi Arabia; 9Department of Anaesthesia and Pain Medicine, ZayedMilitary Hospital, Abu Dhabi, United Arab Emirates; 10Department of Anaesthesia andPain, Drs Nicolas and Asp Medical Centre, Dubai, United Arab Emirates; 11Department ofAnaesthesia, Critical Care and Pain, Sharjah University, Sharjah, United Arab Emirates;12Anaesthesiology Unit, School of Medicine and Pharmacology, University of Western

Australia, Perth, Australia; 13Department of Anaesthesia and Pain Medicine, Royal PerthHospital, Perth, Australia

The findings of an expert panel convenedto review critically how best to applyevidence-based guidelines for thetreatment of acute pain in the Middle Eastregion are presented. The panelrecommended a three-step treatmentprotocol. Patients with mild-to-moderatelevels of acute pain should be treated withparacetamol (step 1). If analgesia isinsufficient after 1 – 2 days, a selectivecyclo-oxygenase-2 inhibitor or, ifgastrointestinal safety and bleeding riskare not an issue, a non-specific non-steroidal anti-inflammatory drug, should

be used (step 2). If analgesia remainsinadequate, treatment with tramadol, orparacetamol plus codeine/tramadol isrecommended (step 3). Patients reportingsevere pain should be referred to a painclinic or specialist for opioid analgesictreatment. Measures of pain andfunctioning that have been validated inArabic, with culturally appropriate andeasy to understand descriptors, should beused. Early and aggressive acute painmanagement is important to reduce therisk of pain becoming chronic, especiallyin the presence of neuropathic features.

KEY WORDS: OPIOID ANALGESICS; NON-NARCOTIC ANALGESICS; NON-STEROIDAL ANTI-INFLAMMATORYDRUGS; SELECTIVE CYCLO-OXYGENASE 2 INHIBITORS; MIDDLE EAST; ACUTE PAIN; GUIDELINES

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AE Ayad, N Ghaly, R Ragab et al.Pharmacological treatment of acute pain in the Middle East

IntroductionPain is the most common reason for seekingmedical care1 but is frequently under-treateddespite the associated enormous healthcarecost, loss of productivity and decreasedability to work.2 The InternationalAssociation for the Study of Pain (IASP)formally defined pain as ‘an unpleasantsensory and emotional experience associatedwith actual or potential tissue damage, ordescribed in terms of such damage’.3,4 Pain iscategorized as acute (‘pain of recent onsetand probable limited duration, usually withan identifiable temporal and causalrelationship to injury or disease’) or chronic(‘commonly persists beyond the time ofhealing of an injury, and frequently theremay not be any clearly identifiable cause’),based on time of onset and duration. The IASP make it clear that the subjective

‘sensory and emotional experience’ of painis as central to its definition as the objectiveneurobiology of nociception,3 and theinherently subjective nature of painnecessitates the use of a biopsychosocialmodel.5,6 Guidelines for the pharmacologicaltreatment of pain must take into accountpsychological and cultural factors that shapethe perception and communication of pain.Conceptualizing pain and its treatmentwithin the context of a patient’s culture isnot simply an academic exercise, but isessential for optimizing accurate assessment,and effectiveness and patients’ acceptance ofevidence-based pain treatment guidelines.Treatment guidelines are one of the most

useful decision-making tools available tophysicians. They are not intended to replaceprofessional experience, but to provide anevidence-based resource that complementsthe expertise of individual physicians. Withthese principles in mind, an expert panelmet to promulgate consensusrecommendations for the pharmacological

treatment of acute pain in the Middle Eastregion (MER), aligned with patient needsand clinical practice. This paper summarizesthe recommendations of this expert panel forthe adaptation of pain assessment andtreatment regimens to the region-specificethnic and cultural realities of the MER. Abrief background on the epidemiology,physiology, psychology and assessment ofacute pain in the MER is provided,highlighting unmet needs and areas thatwould benefit from additional research. Theconsensus recommendations for thepharmacological treatment of acute pain inthe MER are summarized.

ACUTE PAIN: EPIDEMIOLOGY ANDCONSEQUENCES IN THE MERThe causes and clinical situations associatedwith acute pain are highly heterogeneousand the common types and their causes areshown in Table 1. The lifetime prevalence ofacute pain leading to use of analgesics isclose to 100%.7 There are no epidemiologicalsurveys reporting the 1-year prevalence ofspecific acute pain syndromes in thepopulation or in the general practice (GP)setting in the MER, so information must beextrapolated from Western data. Theprevalence of pain varies according toclinical setting; the predominance of acutepain is higher, > 40%,8 – 12 amonghospitalized patients and those presenting tothe emergency department.

ACUTE PAIN: BRIEF REVIEW OFPHYSIOLOGY AND PSYCHOLOGYThe subjective experience of pain may besummarized as a four-stage process.13,14 Instage 1 (transduction) a sensory cell convertsnociceptive environmental stimuli withtissue damaging potential (includingmechanical, chemical and thermal stimuli)into action potentials. Stage 2 (transmission)

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involves the travel of these action potentialsalong afferent neurons to the dorsal horn ofthe spinal cord. In stage 3 (modulation),information on the location, quality andintensity of nociceptive stimuli is codedunder the influence of specificneurotransmitters, other stimuli (e.g. tactile)and descending pathways. Modulation inthe dorsal horn can be excitatory orinhibitory, thereby increasing or decreasingthe resulting pain. The overall subjective

experience of pain is generated in variousparts of the brain in stage 4 (perception),leading to autonomic, affective, cognitiveand behavioural responses to the painfulstimulus.The subjective experience of acute pain is

significantly influenced by psychological,ethnic and sociocultural factors,1,3,4,7 – 21

including emotional state (level of anxiety ordepression) and personality traits (level ofneuroticism, tendency to catastrophize).

TABLE 1: Common types of acute pain and their causes

Types of acute pain Causes of acute pain

Orofacial pain Postdental extractionTonsillectomyPharyngitisMucositis

Systemic medical Acute pain in human immunodeficiency virus infectionconditions Acute cancer pain

Sickle cell crisisAcute cardiac pain

Postoperative Thoracic surgery (thoracotomy)Abdominal surgery (abdominal hysterectomy, colonic resection)Orthopaedic surgery (total hip or total knee arthroplasty, otherelective or emergency surgery)Non-cosmetic breast surgeryLaparascopic surgical procedures (cholecystectomy)HerniorraphyHaemorrhoidectomy

Musculoskeletal pain Acute strains, sprainssecondary to injury, Acute back painsports, etc. Lateral elbow pain (tennis elbow, golfer’s elbow)

Broken bonesHeadache Tension-type headache

MigraineCluster headachePostdural puncture headache

Spinal cord injuryMiscellaneous Acute burn injury

Corneal abrasions DysmenorrhoeaRenal and biliary colicGoutIrritable bowel Herpes zoster

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The subjective nature of pain has severalimportant practical implications. First, theextent of injury does not always correlatewith the severity of pain, since the majordeterminant of pain is not the injury itself,but the body’s reaction to the injury.22,23

Secondly, the complex, multistage processoffers multiple targets for pharmacologicaltreatment and provides a rationale for amultimodal approach. Analgesia may beachieved by reducing the body’s peripheralreaction to injury (via non-specific non-steroidal anti-inflammatory drugs [ns-NSAIDs] or selective cyclo-oxygenase-2[COX-2] inhibitors),24 – 28 blockingtransmission (local anaesthesia),29

enhancing inhibitory modulation (withopioids,30 clonidine31 or antidepressants)32 orreducing excitatory modulation (ketamine,33

pregabalin).34 Thirdly, inhibitory descendingpathways may be augmented by expectation(placebo response),35 physical exercise,36 – 38

or relaxation techniques such as meditation,hypnosis and distraction.39

ACUTE PAIN: PROGRESSION TOCHRONIC PAINAcute pain and chronic pain are not discreteclinical and pathophysiological entities, butlie along a continuum.13 Acute pain, even ofrelatively short duration, activates secondaryperipheral and central mechanisms thatmay result in hyperalgesia andallodynia.22,23 Hyperalgesia is increasedsensitivity to pain, and allodynia is a specialcase of hyperalgesia involving painfulsensations caused by stimuli that do notnormally elicit pain.4 The physiologicalmechanism underlying both hyperalgesiaand allodynia is sensitization, including areduction in pain threshold and increasedintensity of response to a previously painfulstimulus.4 Sensitization may occurperipherally (increased responsiveness of

receptors) or centrally (increasedresponsiveness of secondary neurons in thecentral nervous system to stimuli that mayeven be subthreshold).22,23

The cellular and neurochemicalmechanisms underlying hyperalgesia andallodynia are complex and beyond the scopeof the current article. The clinical implicationsof hyperalgesia and allodynia are important,since individuals who develop sensitizationare at high risk of progressing from acute tochronic pain.40,41 Persistent acute pain thatbecomes chronic is associated with severalnegative consequences, includingsignificantly reduced quality of life, increaseddisability and risk of depression.42 – 44 Despiteconsiderable conflicting data, which recentreviews have attributed to problems withstudy designs, it appears that the aggressiveearly treatment of acute pain may reduce thelikelihood that chronic pain will develop.45

OBJECTIVES The present article has the followingobjectives: (i) to summarize the evidence-based consensus recommendations of anexpert panel for the pharmacologicalmanagement of acute pain in the MER; and(ii) to highlight key clinical areas for futureresearch. The scope of these guidelines islimited to the pharmacologicalmanagement of acute pain. They do notdiscuss the effectiveness of non-pharmacological treatment modalities or themanagement of other pain syndromes, suchas neuropathic or chronic pain.

Materials and methodsA multidisciplinary expert panel withclinical and research expertise in thediagnosis and treatment of acute pain wasconvened in Dubai, United Arab Emirates,on 13 January 2011. The panel includedphysicians from the MER, as well as

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international experts. Relevant publicationssummarizing results of randomizedcontrolled trials were identified via searchesof Medline (PubMed) and the CochraneDatabase. The databases were searchedusing the terms: acute pain OR postoperativepain AND [clinical trials OR meta-analysis]OR [treatment guidelines OR practiceguidelines]. A wider search of the term ‘pain’was also conducted, using the limits[‘English’ AND ‘humans’] AND [‘randomizedclinical trial’ OR ‘review’ OR ‘practiceguideline’]. The results were also looked at toidentify reviews of treatment studies of acutepain that may have been missed. Thecurrent expert consensus panel’srecommendations were based on a review ofmeta-analyses, systematic reviews andevidence-based guidelines on the treatmentof acute pain. The decision was made by theexpert panel not to re-review reports ofindividual randomized clinical trials.Professor SA Schug, a member of the

expert panel, served as one of the editors ofthe most recent edition of Acute PainManagement: Scientific Evidence from theAustralian and New Zealand College ofAnaesthetists and Faculty of Pain Medicine,46

which served as a source document for thecurrent MER-specific guidelines. Additionalrelevant publications were identified viasearches of Medline and the CochraneDatabase. The attendees generated a draftreport and consensus was achieved based oneditorial feedback from the authors.

ResultsASSESSMENT AND MEASUREMENTOF ACUTE PAIN AND TREATMENTRESPONSEThe expert panel concurred that an essentialprecondition for the effective treatment ofacute pain is a thorough medicalexamination. This must include a general

medical history, physical examination tocharacterize the anatomical correlates of thepain and exclude potentially treatablesystemic causes, and a specific history ofpain location and characteristics, includingintensity (at rest or with movement) and anyassociated functional impairment. The advantages and disadvantages of

pain measurement via a visual analoguescale (VAS), numerical rating scale (NRS)and verbal rating scale (VRS) in the MERwere discussed. After reviewing the evidence,the expert panel concluded that the NRS andVRS were more useful than the VAS in the GPsetting and that patient education isimportant to ensure accurate measurement.The expert panel emphasized theimportance of using measures of pain andfunctioning that have been validated inArabic (or the local language), withdescriptors that are both culturallyappropriate and easy to understand withouthigh levels of education. Appendix 1 showsan example of a pain history andexamination worksheet on which patientscan record their pain and functionalimpairment, including pictures of thehuman body (front and back) on which theycan mark the areas where they feel pain.The expert panel concurred that it is

important for GPs to conduct regularassessments of pain intensity and relatedfunctional impairment during treatment inorder to monitor therapeutic effectiveness.Treatment may then be modified, assummarized in later sections of theseguidelines, if improvement has not beenachieved after a reasonable length of time.

CURRENT APPROACH TO ACUTEPAIN: CULTURAL DIMENSIONSEthnic and cultural differences in the MER The MER is a culturally diverse region with apopulation of > 300 million people,

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primarily Arabic speaking andencompassing well over a dozen ethnicgroups. There is enormous diversity ineducational level, per capita income, andrural versus urban residence, frequentlywithin the same nation. The panel noted thelack of empirical research into the impact ofthis ethnic, cultural and educationaldiversity on the experience of acute pain,how it is communicated, and the effect it hason functioning, medical care seeking andresponse to treatment. Significant MER-specific trends that were

noted by the expert panel included the lowrecognition of pain as a ‘fifth vital sign’requiring monitoring and the relativeabsence of medical personnel with specifictraining in pain management. A culturalbias against opioids (‘opiophobia’) wasidentified by the expert panel.47

Unmet needs in the MERAcute pain management has improved overthe last 5 – 7 years in some countries in theMER (Egypt and United Arab Emirates:personal communication, AE Ayad, NGhaly, R Ragab and A Salti), with concertedefforts in major cities being made toimprove the education of GPs andpharmacists in acute pain management.Despite these advances, the expert panelfound that the concept of pain managementis not well established throughout the MER.Adequate financial resources and trainingof sufficient medical personnel with specificexpertise in the management of acute painis still lacking. The expert panel membersagreed that there was considerablediscrepancy between major cities and ruralareas in the level of knowledge of painmanagement, the provision and availabilityof pain management services, and theeducation and training of physicians (bothspecialists and GPs), nurses and allied

healthcare practitioners. Disseminatingpain management expertise to rural areaswas considered to be the most challengingunmet need in the MER. Misconceptionsregarding analgesic use, especially opioids,and fear (of epidural anaesthesia, forexample) that result in under-treatment canonly be overcome with higher levels ofeducation.

GENERAL MANAGEMENTCONSIDERATIONSGeneral management considerations for apatient who presents to a GP with acute painare summarized in Fig. 1. Initial diagnosticevaluation should focus on specific clinicalconcerns, including the presence of comorbidmedical conditions, and any existingtreatment that may influence the choice ofanalgesic or the dose administered. Acutepain treatment is most effective if the patientis given a sense of control by communicatingto them that treatment is a collaborativeendeavour and that their feedback isessential, regarding both the positive effectsof treatment on pain severity andfunctioning and any side effects. It is alsoimportant to educate the patient to ensurerealistic expectations of the achievabledegree of pain relief and the time toresponse. Patients also benefit from knowingthat pharmacological treatment is moreeffective when combined with behaviouralstrategies. These strategies can includephysical measures such as heat, cold, rest orsometimes exercise, the use of distractionand relaxation techniques and, if indicated,the treatment of comorbid anxiety and/ordepression.Treatment progress should be

systematically evaluated on a regular basisby assessing the severity of pain andfunctional impairment, and the treatmentregimen should be adjusted accordingly.

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MILD-TO-MODERATE ACUTE PAIN:MER TREATMENTRECOMMENDATIONSStep 1 recommendation: paracetamolThe consensus MER recommendation forpatients with mild-to-moderate acute pain isto initiate treatment with paracetamol, at amaximum dose of 4 g/day, with a minimum4 h interval between each 1 g dose (Fig. 2).Patients should be clearly instructed to

abstain from using over-the-countercombination analgesics that might containparacetamol in order to avoid accidentaloverdose. Some degree of pain relief isfrequently achieved after a single dose; lackof response after 1 – 2 days suggests thatalternative analgesic treatment isindicated.46,48,49 Patients with an inadequateresponse to paracetamol may be shifted tostronger analgesics, such as ns-NSAIDs or

FIGURE 1: Acute pain: evaluation and treatment flow chart for patients in the MiddleEast region

Patient presenting withacute pain

Perform a diagnostic evaluation – Medical history and physical examination – Evaluate factors that may influence choice and dose of analgesic – Comorbid medical conditions and/or laboratory abnormalities – Current medications with potential drug interaction

Perform assessments – Quantify pain severity using Numerical or Verbal Rating Scales (NRS/VRS) – Quantify pain-related disability/functional impairment using the Functional Assessment Scale

Treat according to stepwise algorithm (Fig. 2) – Educate patient about doses, expected time to treatment response, possible side effects, etc. – Evaluate presence of anxiety and/or depression and treat as necessary – Stress benefits of behavioral interventions (e.g. physical exercise/ activity, relaxation techniques)

Re-evaluate and adjust treatment if indicated – Assess pain severity and functional impairment at regular intervals – Adjust treatment based on assessment of response

Pain is severe/disabling;requires opioids (i.v. or oral)

Yes

No

Refer to specialist for treatment

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selective COX-2 inhibitors (see step 2recommendations, below).46

Intravenous paracetamol has a fasteronset of action and is more efficacious thanoral paracetamol;49 however, intravenousadministration is generally not practical inthe GP setting. The greater efficacy of theintravenous formulation appears to bepartly attributable to the higher systemicconcentration achieved, but may also be dueto the placebo effect associated withreceiving an intravenous infusion.49,50

This paracetamol recommendation isconsistent with previous guidelines46 and the

consensus experience of the expert panel,but it should be noted that there are no well-designed studies evaluating the efficacy andsafety of paracetamol for the treatment ofacute pain in patients in the MER.

Step 2 recommendation: ns-NSAIDs orselective COX-2 inhibitorsThe consensus MER panel recommendedtreatment with a selective COX-2 inhibitor orns-NSAID for patients who have notresponded to a 1 – 2 day period ofparacetamol (Fig. 2).46 The expert panelconcluded that oral or parenteral ns-NSAIDs

FIGURE 2: Acute pain: treatment algorithm by severity category for patients in theMiddle East region (coxib, selective COX-2 inhibitor; ns-NSAID, non-specific non-steroidal anti-inflammatory drug)

Acute painsevere

Opioids – Refer patient to pain clinic or specialist

Acute painmild or moderate

Step 1: paracetamol – 4 g/day maximum dose – 4 h minimum interval between each 1 g dose

Step 2: coxib or ns-NSAID – Make choice based on patient risk profile

Step 3: add to coxib or ns-NSAID one of the following: – Paracetamol/codeine combination – Paracetamol/tramadol combination – Tramadol

Acute pain

Topical ns-NSAID (gel or cream) – With or without combined oral paracetamol or coxib or ns-NSAID

– Acute sport injury – Acute traumatic or inflammatory condition – Acute musculoskeletal injury

Inadequate analgaesia

Inadequate analgaesia

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and selective COX-2 inhibitors are similarlyeffective in the management of acutepain.51,52 Selective COX-2 inhibitors arepreferred to ns-NSAIDs due to their lowerincidence of adverse events and greatergastrointestinal safety.46 The gastrointestinalsafety advantage of selective COX-2 inhibitorshas been recently confirmed in a large (4448patient) double-blind, placebo-controlled, 6-month trial that found celecoxib treatment tobe associated with significantly fewer adversegastrointestinal events than ns-NSAIDs, evenwhen administered with a proton pumpinhibitor.53 The expert panel noted that thereis a perception among MER physicians thatselective COX-2 inhibitors are less effective foracute pain; however, the data have clearlyestablished that choosing a selective COX-2inhibitor as a safer alternative does notsacrifice analgesic potency in acute painmanagement.46

The preferred profile of a candidate fortreatment with an ns-NSAID class drug is arelatively young patient (< 65 years) with nohistory of gastrointestinal disease or adversegastrointestinal events during previoustreatment.54 – 57 First-line ns-NSAID treatmentis not recommended in patients with ahistory of ulcers or gastrointestinal bleeding,gastro-oesophageal reflux disease, or in thosewith traumatic and/or perioperative painwho are at increased bleeding risk;46 ns-NSAID treatment is also not recommendedfor patients undergoing current treatmentwith aspirin or other anticoagulants.58

Treatment with a selective COX-2inhibitor is recommended in elderly patients(≥ 65 years) and those with traumatic orpostoperative pain, even in the absence of ahistory of gastrointestinal events. SelectiveCOX-2 inhibitors do not impair plateletfunction and perioperative treatment withselective COX-2 inhibitors does not increasethe risk of significant postoperative

bleeding.59,60 Treatment with a selectiveCOX-2 inhibitor, preferably combined with aproton pump inhibitor, is also recommendedin patients with a history of gastrointestinalevents, or aspirin users.61,62

Comparative analyses of cardiovascularrisk have found no difference in theincidence of myocardial infarction or othercardiovascular complications in patientstreated with selective COX-2 inhibitors or ns-NSAIDs.63 – 65 The US Food and DrugAdministration has stated that ‘short-termuse of NSAIDs to relieve acute pain,particularly at low doses, does not appear toconfer an increased risk of serious adversecardiovascular events’;63 this statementrefers to ns-NSAIDs, such as ibuprofen.

Step 3 recommendation: combinationtherapyThe analgesic effect of selective COX-2inhibitors and ns-NSAIDs may be augmentedby combination therapy with paracetamol inpatients with a partial response to selectiveCOX-2 inhibitor/ns-NSAID monotherapy (Fig.2).46 The expert panel recommended step 3combination therapy with eitherparacetamol/tramadol or paracetamol/codeine, both of which are availablethroughout most of the MER, for patients whohave achieved inadequate analgesia in step 2.Other combinations of paracetamol withopioids may also be effective. Meta-analyses ofcontrolled trials have found that paracetamolcombined with either tramadol or codeine ismore effective than monotherapy with eitherdrug class.66,67 A clear dose–response effect isobserved for combination therapy. If paincontrol is not achieved after a reasonablelength of time, other causes of pain should beinvestigated and the treatment plan should becritically reviewed. Combination treatmentwith strong opioids, if available, may beindicated in these cases.

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SEVERE ACUTE PAIN: MERTREATMENT RECOMMENDATIONSThe choice of a first-line analgesic for thetreatment of acute pain should be selectedbased on pain severity. Patients who presentwith severe acute pain, especially ifassociated with significant functionalimpairment, should receive opioidanalgesics as first-line treatment (Fig. 2).46

Access to potent opioid analgesics is greatlyrestricted in the MER primary care/GPsetting; patients with severe and/or disablingacute pain should generally be referred to apain clinic or specialist to receive treatment. If opioid analgesics are available, the

preferred route of administration is oral, orintravenous if oral administration is notclinically appropriate, rather thansubcutaneous or intramuscular.68,69

Intramuscular opioid analgesics should beavoided as far as possible due to inconsistentpain relief.70 Intravenous administration, ifpossible via intermittent bolus, isrecommended for rapid control of severeacute pain since drug absorption by otherroutes is delayed and/or unpredictable.Intravenous administration of opioidanalgesics is associated with an increasedrisk of respiratory depression, so must beclosely monitored. Sedation precedesrespiratory depression so it is especiallyimportant to monitor the level of sedation asan important warning sign of potentiallyimpending respiratory depression.

ACUTE PAIN DUE TOMUSCULOSKELETAL INJURY: MERTREATMENT RECOMMENDATIONSThe most frequent causes of mild-to-moderate acute pain are traumatic andinflammatory musculoskeletal conditionscaused by traumatic or sports injuries. Ingeneral, topical NSAIDs are effective forshort-term (up to 1 week) treatment of acute

strains, sprains or other sports-relatedmusculoskeletal injuries (Fig. 2). Cross-studycomparisons have suggested that topicalketoprofen and diclofenac may be the mosteffective agents,71 – 75 whereas topicalindomethacin has shown no better efficacythan placebo.76 A review of availableevidence suggests that topical NSAIDs mayhave limited efficacy for specificmusculoskeletal conditions such astendonitis, especially Achilles tendonitis andlateral elbow pain. Topical NSAIDs havefewer gastrointestinal side effects than oralNSAIDs.75 For many sports injuries,especially involving soft tissues, ns-NSAIDsand selective COX-2 inhibitors appear tohave similar analgesic efficacy; however,selective COX-2 inhibitors cause lessgastrointestinal bleeding.52 Anecdotalevidence suggests that combined use oftopical NSAIDs with oral paracetamol,selective COX-2 inhibitors or ns-NSAIDs mayresult in increased analgesia; however,insufficient randomized controlled trial dataare available to confirm this.

SPECIFIC ACUTE PAIN SYNDROMESThe expert panel reviewed two acute patientsyndromes that are common in the primarycare setting: acute back pain andpostoperative pain.

Acute back painAcute back pain, typically lumbar or sacraland lasting ≥ 2 weeks, has a lifetimeprevalence of 14%.77 Transient cases of low-back pain occur in > 75% of individuals atsome time in their lives.78 In approximately95% of cases, the cause of acute low-backpain is non-specific and self-limiting.79,80

The most important initial goal in themanagement of acute low-back pain is toidentify the 5% of patients who have anunderlying pain-causing condition that is

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either serious or treatable. The AustralianAcute Musculoskeletal Pain GuidelinesGroup81 have summarized the key signs andsymptoms (‘red flags’) associated with anincreased likelihood of an underlyingcondition. The most common ‘red flags’ thatmust be evaluated and ruled out aresummarized in Table 2. A full neurologicalexamination is indicated for any patientwho presents with lower limb pain orneurological symptoms (including weakness,foot drop, cauda equina syndrome and lossof bladder and/or bowel control). While it isnecesssary to rule out potentially seriouscauses, it is important for GPs to rememberthat many clinical and radiological findings

occur in asymptomatic patients and may notbe the actual cause of pain. For this reason,lumbar X-rays are not routinelyrecommended for uncomplicated low-backpain with no ‘red flags’.81

Pharmacological treatment of low-backpain should follow the same step-wiseprocedure outlined in Fig. 2, based on painseverity. A multimodal approach to treatmentis especially important in the effectivemanagement of acute low-back pain,including encouraging the individual to avoidbed-rest and stay active, minimize the time offwork and generally attempt to maintain theirformer level of functioning. The main goal ofanalgesic medication is to enable functional

TABLE 2: ‘Red flags’ and ‘yellow flags’ in the treatment of acute low-back pain

‘Red flags’81

Acute low-back pain associated with one of the Pain may be due to a following signs/symptoms/risk factors serious condition

Fever, chills Infection (osteomyelitis; Generalized fatigue or malaise epidural abscess; renal Risk factors: recent penetrating wound, infection)immunosuppression, underlying systemic disease

Recent history of trauma FractureRisk factors: age > 50 years, history of osteoporosis, corticosteroid use

Past history of malignancy Tumour (primary: myeloma, Age > 50 years bone, cartilage, neuronal; Failure to improve with treatment secondary: prostate, breast, Unexplained weight loss lung, thyroid, kidney, Pain at multiple sites gastrointestinal, melanoma)Pain at rest

Pain is not associated with any aggravating factors Visceral referred pain (aortic aneurysm;pancreatitis; pelvic disease)

‘Yellow flags’81

Psychosocial factors that may increase the risk of acute low-back pain becoming chronic

Attitudes and beliefs about pain – negative attitude, pain viewed as disabling, high neuroticismBehaviour – poor coping skillsCompensation issues – filing or receiving disability for back painEmotions – symptoms of depressionFamily – poor social support, perceived excessive stress/demandsWork – job dissatisfaction

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recovery. Failure to adopt a multimodalapproach to therapy increases the risk thatacute low-back pain will become a chronicand disabling condition. Psychosocial andoccupational factors (‘yellow flags’)81 thatappear to be associated with an increased riskof progression from acute to chronic low-backpain have been identified and these should beassessed early in order to facilitateappropriate intervention (Table 2).82

Acute postoperative painPostoperative pain is a common type ofacute pain (Table 1). A large proportion ofsurgical procedures now occur in anambulatory or short-stay setting. Effectivepain management is one of the primaryconsiderations in determining whethersurgery can be accomplished in anambulatory setting or on a short-stay basis,and inadequate analgesia is the mostcommon cause of delay to discharge andrecovery.83 – 85

Evidence-based, procedure-specificpostoperative pain managementrecommendations have been developed bythe PROSPECT (PROcedure-SPECific clinicaldecision support for postoperative painmanagemenT) Working Group for a widerange of surgical procedures.86 Many of thesame general management principlessummarized in previous sections of thesecurrent guidelines also apply to acutepostoperative pain. Prior to a surgicalprocedure, GPs should educate their patientson the likelihood of acute postoperativepain, allowing patients to be better preparedmentally and helping them to cope. It isimportant to minimize the number of daysoff work after surgery and the GP shouldpromote a return to normal activities asquickly as possible. Postoperative pain has a high risk of

progressing to chronic pain because of the

frequent occurrence of neuropathiccomplications due to surgery-related nerveinjury. It is, therefore, especially importantthat postoperative pain be treated early andaggressively. Management of postoperativepain may require the involvement ofanaesthetists and treatment with regionalanaesthesia and analgesia.46

PROGRESSION FROM ACUTE TOCHRONIC PAINOne of the most important goals in themanagement of acute pain is to preventprogression to a chronic pain state. Chronicor persistent pain is associated with a highdegree of disability and a lower treatmentresponse rate.87 – 89 Specific acute painconditions, such as herpes zoster, back pain,postoperative pain and pain due to injury,are associated with a significantly higher riskof progression to chronic pain.42,43,90 – 94

Factors predicting progression from acute tochronic pain include severity of pain, nerveinjury, the presence of clinically significantanxiety and/or depression and psychosocialfactors such as high levels of neuroticism orcatastrophizing.41,46,90 – 94

The expert panel recommended that GPsprovide early diagnosis and appropriatepharmacological treatment in order toreduce the likelihood of progression tochronic pain in high-risk individuals. Theyalso referred to the importance of screeningpatients for other risk factors, since amultimodal treatment approach is moreeffective. Exercising and otherwisemaintaining activity levels must beencouraged; early return to work should bepromoted whilst also reassuring patientsthat they will have the pharmacologicaltools available to assist them in thetransition back to work. Treatablepsychological problems, such as anxiety anddepression, occur in > 25% of patients at risk

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for chronicity95 – 97 and should be screenedfor and appropriately treated. Some analgesic interventions in the

treatment of postoperative pain have aneffect, known as preventive analgesia, thatexceeds the expected duration of action of thedrug.45 Aggressive preventive analgesia hasbeen shown to reduce overall postoperativeanalgesic consumption45 and may reduce therisk of acute pain becoming chronic orneuropathic in nature. Regional anaesthesiahas been shown to be effective in reducingthe progression from acute to chronicpostoperative pain in some pain settings.46

SummaryPain is the most common reason for seekingmedical care1 and is frequently under-treated.2 The present article summarizesexpert panel consensus recommendationsfor the treatment of acute pain in the MER,focusing mostly on treatments available inoutpatient general practice. Treatmentrecommendations were based oncategorizing acute pain into two severitycategories, mild-to-moderate and severe,with a third category, not based on painseverity, for acute pain due tomusculoskeletal injury from sport or othertrauma.In patients with mild-to-moderate levels

of acute pain, the recommendation is toinitiate treatment with a maximum dose of 4g/day paracetamol, with a minimum 4 hinterval between each 1 g dose (step 1).Patients who do not achieve sufficientanalgesia within 1 – 2 days should switch toa selective COX-2 inhibitor or, ifgastrointestinal safety and risk of bleedingare not an issue, a ns-NSAID (step 2). Ifanalgesia continues to be inadequate, therecommendation is to add tramadol, orcombination therapy with paracetamol pluseither codeine or tramadol (step 3).

Patients reporting severe pain should bereferred to a pain clinic or specialist fortreatment with an opioid analgesic. Treatment with an oral selective COX-2

inhibitor or topical ns-NSAID gel or cream,or a combination of oral and topicaltreatments, was recommended for patientswith acute pain from musculoskeletal injurydue to sport or other trauma.The expert panel emphasized the

importance of using measures of pain andfunctioning that have been validated inArabic (or the local language), usingdescriptors that are both culturallyappropriate and easy to understand withouthigh levels of education. They also stressedthe importance of early and aggressivetreatment of acute pain in order to reducethe risk of pain becoming chronic orneuropathic in nature.

Conflicts of interestDr N Ghaly, Dr R Ragab, Dr S Majeed, Dr AAl Jalabi, Dr A Al Shoaibi, Dr S El Noor andDr J Costandi all had no conflicts of interestto declare in relation to this article. Dr AEAyad is in receipt of a speaking honorariumfrom Lilly. Dr H Nassar is in receipt of aspeaking honorarium from Pfizer. Dr AZeidan receives consulting payments fromMSD and Pfizer. Dr A Salti receives speakingand/or consulting honoraria or paymentsfrom GE Ultrasound and Baxter. Professor SASchug (in his role at the Anaesthesiology Unitof the University of Western Australia) hasreceived research and travel funding, andspeaking and consulting honoraria fromGruenenthal, CSL, Janssen Pharmaceuticalsand Pfizer within the last 2 years. Medical writing support, including

coordinating the editorial feedback from theexpert panel authors, was provided by Dr ESchweizer of Paladin Consulting Group andwas funded by Pfizer.

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Appendix 1Example of a pain history and examination worksheet on which patients canrecord their pain and functional impairment, including pictures of the humanbody (front and back) on which they can mark the areas where they feel pain.

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• Received for publication 18 May 2011 • Accepted subject to revision 26 May 2011 • Revised accepted 7 July 2011

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Authors’ addresses for correspondenceDr Abbas Al Jalabi

Department of Anaesthesia, PO Box 3050, Hamad Medical Corporation, Doha, Qatar.E-mail: [email protected]

Dr Ammar SaltiDepartment of Anaesthesia and Pain Medicine, Zayed Military Hospital, PO Box 4638, Abu

Dhabi, United Arab Emirates.E-mail: [email protected]

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