EFIC Position Papers

The European Pain Federation EFIC produces its own position papers, documents and standards on the topics of relevance to our work, our community and the education and management of pain.

NEW Opioids for Chronic Non-Cancer Pain – CONSULTATION

The purpose of this position paper is to promote safe decision-making and, if warranted, safe prescribing of opioids for patients of any age with chronic non-cancer pain. For this project, EFIC created a multidisciplinary task force, ensuring a balanced view representing all professions and medical disciplines pertinent to the subject. EFIC also included a patient representative as an author.

The work of the task force has now concluded, with a draft manuscript ready for pre-publication peer-review. Before this manuscript is presented to a peer-reviewed indexed journal, EFIC consider it important to receive feedback on the text from the wider pain community. Following standard practice for medical guidelines in Germany, EFIC present the document for comments from all stakeholders with an interest in and expertise on the subject. The deadline for consultation has ended on 26th of July 2020. All commentary will be reviewed before publishing the paper later this year. Should you have any questions regarding the task force please contact sara.badreh@efic.org for more information.

Standards for the diagnosis and management of complex regional pain syndrome


Complex regional pain syndrome is a painful and disabling post‐traumatic primary pain disorder. Acute and chronic complex regional pain syndrome (CRPS) are major clinical challenges. In Europe, progress is hampered by significant heterogeneity in clinical practice. We sought to establish standards for the diagnosis and management of CRPS.


The European Pain Federation established a pan‐European task force of experts in CRPS who followed a four‐stage consensus challenge process to produce mandatory quality standards worded as grammatically imperative (must‐do) statements.


We developed 17 standards in 8 areas of care. There are 2 standards in diagnosis, 1 in multidisciplinary care, 1 in assessment, 3 for care pathways, 1 in information and education, 4 in pain management, 3 in physical rehabilitation and 2 on distress management. The standards are presented and summarized, and their generation and consequences were discussed. Also presented are domains of practice for which no agreement on a standard could be reached. Areas of research needed to improve the validity and uptake of these standards are discussed.


The European Pain Federation task force present 17 standards of the diagnosis and management of CRPS for use in Europe. These are considered achievable for most countries and aspirational for a minority of countries depending on their healthcare resource and structures.

Read the full paper here: https://onlinelibrary.wiley.com/doi/10.1002/ejp.1362

Standards for the management of cancer‐related pain across Europe

Standards for the management of cancer‐related pain across Europe: A position paper from the EFIC Task Force on Cancer Pain

Background and objective

Pain is a common symptom in patients who survive cancer and in those who live with progressive advanced disease. Evidence from meta‐analyses suggests that pain remains poorly controlled for a large proportion of patients; barriers to good management include poor assessment of pain, inadequate support for patient self‐management and late or inadequate access to strong opioid analgesia in those with advanced disease.


The European Pain Federation (EFIC) established a Task Force in 2017 which convened a European group of experts, drawn from a diverse range of relevant clinical disciplines, to prepare a position paper on appropriate standards for the management of cancer‐related pain. The expert panel reviewed the available literature and made recommendations using the GRADE system to combine quality of evidence with strength of recommendation. The panel took into account the desirable and undesirable effects of the management recommendation, including the cost and inconvenience of each when deciding the recommendation.

Results and conclusions

The 10 standards presented are aimed to improve cancer pain management and reduce variation in practice across Europe. The Task Force believes that adoption of these standards by all 37 countries will promote the quality of care of patients with cancer‐related pain and reduce unnecessary suffering.


Pain affects up to 40% of cancer survivors and affects at least 66% of patients with advanced progressive disease, many of whom experience poor pain control. These 10 standards are aimed to improve cancer pain management, promote the quality of care of patients and reduce variation across Europe.

Read the whole paper here
Cannabis‐based medicines and medical cannabis for chronic pain management

European Pain Federation (EFIC) position paper on appropriate use of cannabis‐based medicines and medical cannabis for chronic pain management

Cannabis‐based medicines are being approved for pain management in an increasing number of European countries. There are uncertainties and controversies on the role and appropriate use of cannabis‐based medicines for the management of chronic pain. EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper to empower and inform specialist and nonspecialist prescribers on appropriate use of cannabis‐based medicines for chronic pain. The expert panel reviewed the available literature and harnessed the clinical experience to produce these series of recommendations. Therapy with cannabis‐based medicines should only be considered by experienced clinicians as part of a multidisciplinary treatment and preferably as adjunctive medication if guideline‐recommended first‐ and second‐line therapies have not provided sufficient efficacy or tolerability. The quantity and quality of evidence are such that cannabis‐based medicines may be reasonably considered for chronic neuropathic pain. For all other chronic pain conditions (cancer, non‐neuropathic noncancer pain), the use of cannabis‐based medicines should be regarded as an individual therapeutic trial. Realistic goals of therapy have to be defined. All patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to reach the predefined goals and/or the patient is additionally burdened by an unacceptable level of adverse effects and/or there are signs of abuse and misuse of the drug by the patient, therapy with cannabis‐based medicines should be terminated.

Please access the full text on the European Journal of Pain here
Use of opioids for pain management

While opioid prescription and use for pain management is a major concern in some parts of the world, the context of opioid use clearly differs between countries. Many countries in Europe have in place significant barriers to optimal pain management due to inappropriate restrictions on supply and use. Opioids are an important part of a modern approach to pain management and palliative care, and misplaced barriers to access can lead to unnecessary suffering.

Opioids are not a panacea for all types of pain, and must only be used in selected and supervised pain patients as part of a comprehensive, multi-modal, multi-disciplinary approach to treatment. In this context alone, opioid therapy is an essential and indispensable tool in achieving and maintaining an optimal level of pain control in selected patients.

The European Pain Federation calls for continuous medical education on the correct use of opioids in multi-professional and multi-modal therapeutic approaches. We also call for enhancing access to comprehensive pain assessment clinics and therapies and increasing funds for robust research on pain management.

Please find the full European Pain Federation position paper on appropriate opioid use in chronic pain management here.

Position Papers Endorsed by EFIC

Pathophysiology and management of opioid-induced constipation: European expert consensus statement

Pathophysiology and management of opioid-induced constipation: European expert consensus statement



Opioid-induced bowel dysfunction is a complication of opioid therapy, in which constipation is the most common and problematic symptom. However, it is frequently under-recognised and thus effective management is often not instituted despite a number of treatment options.



The central objective of this study is to provide a summary of the pathophysiology and clinical evaluation of opioid-induced constipation and to provide a pragmatic management algorithm for day-to-day clinical practice.



This summary and the treatment algorithm is based on the opinion of a European expert panel evaluating current evidence in the literature.



The pathophysiology of opioid-induced constipation is multi-faceted. The key aspect of managing opioid-induced constipation is early recognition. Specific management includes increasing fluid intake, exercise and standard laxatives as well as addressing exacerbating factors. The Bowel Function Index is a useful way of objectively evaluating severity of opioid-induced constipation and monitoring response. Second-line treatments can be considered in those with recalcitrant symptoms, which include gut-restricted or peripherally acting mu-opioid receptor antagonists. However, a combination of interventions may be needed.



Opioid-induced constipation is a common, yet under-recognised and undertreated, complication of opioid therapy. We provide a pragmatic step-wise approach to opioid-induced constipation, which should simplify management for clinicians.

Full text available here.