The Pain Management Core Curriculum for European Medical Schools

Section 1. Introduction: principles of pain management

3 domains · the foundation for all subsequent modules

• 1.1 Principles of pain management. The definition of pain and the bio-psycho-social model, including the point that pain can develop and persist without a physical lesion; the physiology of pain, covering transduction, transmission, and central processing, and the mechanisms of peripheral and central sensitisation; the psychology of pain, covering affective, cognitive, and behavioural factors, social influences, psychiatric and psychosomatic comorbidity, and the placebo effect; the classification of pain as acute or chronic and as nociceptive or neuropathic; treatment indications; and the comorbidities typically associated with pain.
• 1.2 Diagnosis. Taking a structured pain history, physical examination, diagnostic tools, and differential blocks, together with the pain rating tools students are expected to be able to use: analogue scales, questionnaires, and pain diaries.
• 1.3 Principles of pain treatment. Treating cause and symptom; pharmacological management covering opioids, non-opioid analgesics, and co-analgesics; non-pharmacological management covering psychological therapy, counter-irritation procedures, and physiotherapy; the principle that invasive approaches are generally reserved for when simpler ones have failed; patient education; and multidisciplinary pain management programmes based on cognitive-behavioural principles.

Section 2. Acute pain: post-operative and post-traumatic pain

Acute pain is framed as having a warning function, in contrast to most chronic pain, and as carrying a real physiological cost if left untreated. Students are expected to know the post-operative stress response system by system, from tachycardia and increased myocardial oxygen demand through pain-induced hypoventilation to gastric atony and raised thrombo-embolism risk, and to understand that treating the pain is a means of organ protection and earlier mobilisation, not only of comfort.

The applied content covers measuring pain intensity on a numerical rating scale, the hierarchy of administration routes and the exceptions to it, the stepwise approach to acute pain management, the handling of a pain emergency, and specific procedures including regional anaesthesia and patient-controlled analgesia.

Section 3. Cancer pain

Students are expected to know the aetiology of cancer pain and to distinguish pain caused by the tumour or its metastases, pain caused by treatment such as post-operative wound pain, mucositis, or chemotherapy-induced neuropathy, and pain that is unrelated to the cancer altogether.

The core skill is applying the WHO Pain Relief Ladder across its three steps, with attention to co-analgesics where there is a neuropathic component, and understanding that invasive or neurodestructive procedures follow only after the stepped approach has failed. The section also covers the national prescription regulations for opioids and how to complete a controlled-drug prescription correctly.

Section 4. Neuropathic pain

Neuropathic pain is defined by a primary lesion or disease of the nervous system, with the observation that many pain syndromes have both nociceptive and neuropathic components and that conventional analgesics often control neuropathic pain poorly.

Students are expected to understand and use the terms allodynia and hyperalgesia, to recognise the value of a careful history and sensory examination in localising the lesion to a specific nerve or root, and to know the cause, presentation, and treatment of two typical conditions. Two are worked through as examples: polyneuropathy (4.1) and herpes zoster (4.2).

Section 5. Development of pain chronicity

This section teaches the distinction between acute and chronic pain and, importantly, treats chronic pain as a condition in its own right rather than as prolonged acute pain. Students learn that chronic pain has lost its warning function, that it expands beyond the physical into psychological and social dimensions, that managing it by the principles of acute pain management generally fails, and that the signs of developing chronicity need to be recognised early so that an appropriate plan can be put in place.

Two worked examples: chronic non-specific back pain (5.1), including its incidence, prevalence, and socio-economic cost, the differential diagnosis for specific back pain, and the fact that more than 90 per cent of cases have no specific aetiology; and medication-overuse headache (5.2).

Section 6. Specific therapeutic populations and challenges

Optional module, or integrated into modules 1 to 5

• 6.1 Children. That the responsibility to relieve pain applies equally to infants and children; the heightened pain sensitivity of premature and newborn infants and the possible lifelong consequences of untreated pain; observational assessment using physiological signs, vocalisation, facial expression, motor and sensory changes, and vegetative signs; age-appropriate assessment tools; the principal paediatric analgesics with their indications, weight-based dosing, and side effects; the particular risks of acetylsalicylic acid in children; off-label prescribing; and the availability of non-pharmacological approaches.
• 6.2 Old age and dementia. That older people living with pain are frequently undertreated, and why: communication barriers, gaps in knowledge about medication in older age, and assumptions about pain sensitivity in dementia. Covers the epidemiology of pain in later life, age-related changes in nociception and central processing, age-related coping styles, psychological comorbidity, the continued usefulness of analogue scales despite cognitive limitation, observational indicators of pain in people unable to communicate, reduced hepatic and renal clearance, polypharmacy, and risks such as opioid-related falls and confusion.
• 6.3 Pregnancy and breastfeeding. The restricted evidence base for drug safety; risks to the foetus and newborn including neonatal withdrawal and respiratory depression after opioid exposure, premature closure of the ductus arteriosus with NSAIDs in the third trimester, and transfer of medication into breast milk; appropriate procedures and analgesics for pain in labour; and the teratogenic risks of common co-analgesics for women with chronic pain who may become pregnant.
• 6.4 Addiction and dependence. A balanced approach in which students learn to reduce abuse, addiction, and diversion while recognising the essential medical role of opioid medicines. Covers the definitions of dependence, abuse, and addiction as distinct concepts, the predictors of problematic use, and practical safeguards: screening all patients for prior substance use, giving explicit instructions, and monitoring use over time.