Using Drugs for Pain Prevention: Primary Prevention Across Areas

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Using Drugs for Pain Prevention: Primary Prevention Across Areas
疼痛的药物预防
Introduction
Chronic pain may occur after surgery, trauma, cancer treatment or infection. In the majority of patientsenduring chronic pain, a neuropathic or nociplastic component is present which increases pain severityand worsens the quality of life [8]. The transition from acute to chronic pain is a complex processinvolving multiple biopsychosocial mechanisms. Current knowledge favors mechanisms in relation toboth peripheral (at the site of tissue trauma) and central (spinal and supraspinal) sensitization. Drugshave been used to prevent the development of chronic pain, specifically drugs which target spinalexcitatory processes and/or which display anti-inflammatory properties able to modulate the release ofcytokines from peripheral immune cells and central glial cells.

Drugs for Primary Pain Prevention
The largest bulk of research on the prevention of chronic pain has focused on chronic postsurgical pain,as surgery constitutes one of the common causes of pain and is often scheduled which makespreventive strategies easier to apply. Nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamineand memantine have shown some but inconstant efficacy as preventive analgesics for surgical patients(Please see the IASP fact sheet “Prevention of pain after surgery”).

Complex Regional Pain Syndrome type 1 (CRPS-I) is a debilitating chronic pain condition which developsafter an inciting event, often minor trauma or surgery, and involves chronic regional paindisproportionate to the causal event. CRPS-I should be distinguished from CRPS type 2, previously calledcausalgia, where the symptoms are due to nerve damage. The knowledge of the mechanisms of CRPS-Iis constantly evolving. CRPS exhibits classic neuropathic pain characteristics but is associated with higherphysical disability which considerably lengthens the time of recovery [2]. People who have
developedCRPS-I may be at a high risk of recurrence following another trauma or surgical event. Vitamin Csupplementation (500 to 1000mg a day for at least 50 days intake) is reported to decrease the risk ofdeveloping CRPS type I following wrist fracture and/ or extremity surgery [1, 4]. Vitamin C is a welldocumented antioxidant with low risk of toxicity
Cancer treatment with chemotherapy is known to cause neuropathic pain in 25–50% of patients [5]resulting in an impairment of quality of life. Prevention of chemotherapy-induced pain withanticonvulsants or tricyclic antidepressants has so far not proved very successful [6], but there is someevidence for duloxetine or memantine [7]. Randomized controlled trials and observational studies areneeded to achieve clinical significance.

Infection may also have long-standing pain consequences. For example, herpes zoster infection, apainful, blistering skin eruption in a dermatomal distribution caused by reactivation of a latent varicella

zoster virus in the dorsal root ganglia may result in chronic neuropathic pain (post-herpetic neuralgia).Although varicella and zoster vaccines have made major inroads into reducing the burden of diseaseglobally, thus reducing the risk of post-herpetic neuralgia [9], there is currently insufficient evidence todetermine the beneficial effect of other antiviral treatments [3].

ConclusionThe prevention of chronic pain remains an area of unmet clinical need. Additional well-designed studiesare necessary to determine the overall effectiveness, adverse effects as well as duration of treatmentand optimal dosage of preventive drugs. An important step has been done by the inclusion of chronicpain whatever its origin in the current International Classification of Diseases (ICD-11) [8]. Hopefully,this will increase focus on chronic pain and promote research in the field, including the development ofpreventive strategies.

AUTHORSProfessor Gisèle Pickering, MD, PhD, DPharm,Clinical Pharmacology Department, CPC/CICUniversity Hospital CHUClermont-Ferrand, FranceProfessor Patricia Lavandhomme MD, PhD,Department of Anesthesiology and Postoperative Pain ServiceCliniques Universitaires St LucUniversité Catholique de LouvainBrussels, BelgiumREVIEWERSRae Bell, MD, PhDCentre for Pain Management and Palliative CareHaukeland University HospitalBergen, NorwayChristian Duale, MDClinical Pharmacology Department, CPC/CICUniversity Hospital CHUClermont-Ferrand, FranceAnne BerquinClinques Universitaires St LucBrussels, Belgium
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