EFIC Position and Opinion Papers

Pain is the leading cause of disability worldwide, yet pain research remains underfunded and underfocused. Using literature review, expert debate, a survey of 628 European researchers, clinicians, educators, and industry professionals, and a consensus meeting involving people with lived experience from 23 countries, EFIC identified five top priorities: understanding the pathophysiology of pain, addressing comorbidities, critically assessing current therapies, developing new treatments, and exploring the biopsychosocial impacts of pain. Physical, psychological, and social approaches were prioritised at the same level as pharmacological treatments. Wide implementation is intended to direct funding, reduce research waste, and speed the translation of evidence into practice.

Physical activity benefits pain and overall health, but many people living with chronic pain find it challenging and many health professionals report barriers to promoting it. Prepared by the 'On The Move' Task Force and endorsed by the European Pain Forum, Pain Alliance Europe, and the EFIC Executive Board, this paper sets out five recommendations: take a physical activity history, advise that activity is important and safe, deliver a brief intervention, discuss acceptable levels of activity-related soreness, and provide ongoing support. Physical activity is low-cost, low-risk, and does not require access to healthcare, and adopting these recommendations can improve quality of care and life while reducing overall health risks.

A systematic review assessed the sensitivity and specificity of screening tools and of quantitative sensory testing, neurophysiology, skin biopsy, and corneal confocal microscopy for neuropathic pain. DN4, I-DN4, and LANSS received strong recommendations as screening tools, skin biopsy received a strong recommendation, and trigeminal reflex testing received a strong recommendation for diagnosing secondary trigeminal neuralgia. Quantitative sensory testing and nociceptive evoked potentials received weak recommendations. The authors note that the poor-to-moderate quality of available evidence means larger, well-designed multicentre studies are still needed.

In the absence of pan-European guidance, EFIC coordinated eight scientific societies and one patient organisation to develop these recommendations, using a systematic MEDLINE review and the GRADE system. They advise optimising non-pharmacological treatments and non-opioid analgesics first, and considering opioids only where those options are ineffective, not tolerated, or contraindicated. Eighteen Good Clinical Practice statements cover evaluation, assessment, monitoring, continuation, and discontinuation. Opioids should be neither embraced as a cure-all nor dismissed as universally dangerous, but reserved for selected patients as part of a multimodal, multidisciplinary approach.

Developed by the same EFIC-coordinated task force and methodology as Part 1, this paper addresses opioid use in special situations. It gives guidance on combining opioids with other medications, managing frequent side effects such as nausea and constipation and rare ones such as hyperalgesia, and treating special populations including children and adolescents and pregnancy, and clinical situations such as liver cirrhosis. Where a trial of opioids is conducted, detailed knowledge and collaboration across specialties and health professions are needed to adapt treatment and manage side effects effectively.

Despite major advances in understanding pain physiology and pathophysiology, this progress has not translated into effective new treatments for acute and chronic pain, which remain an unmet medical need. Bringing together researchers from different disciplines, this paper reviews the factors that limit translation, including interspecies differences, the limited validity of preclinical pain models, and the limitations of current methods for assessing nociception and pain. It explores ways forward, including back-translation from patients into more clinically relevant disease models, accounting for age and sex differences, and integrating psychobiology into translational pain research.

Complex regional pain syndrome is a painful and disabling post-traumatic primary pain disorder, and progress in Europe is hampered by wide variation in clinical practice. A pan-European EFIC task force used a four-stage consensus process to produce 17 mandatory quality standards across eight areas of care: diagnosis, multidisciplinary care, assessment, care pathways, information and education, pain management, physical rehabilitation, and distress management. The standards are considered achievable for most countries and aspirational for a minority, depending on healthcare resources and structures.

Pain remains poorly controlled for many people living with or surviving cancer, with barriers including poor assessment, inadequate support for self-management, and late or inadequate access to strong opioids. An EFIC task force convened in 2017 drew on a diverse range of clinical disciplines and used the GRADE system to produce 10 standards for the management of cancer-related pain. The standards aim to improve quality of care and reduce variation in practice across Europe.

Public interest in cannabis products for medical use has grown, but European countries differ widely in availability, use, and reimbursement, and systematic reviews reach partly divergent conclusions on efficacy and safety. This EFIC task force paper provides a fair, balanced, and evidence-based summary of the role of cannabis-based medicines in pain management, drawing on 15 systematic reviews and five sets of guidelines or recommendations. It offers recommendations for prescribers on the appropriate use of cannabis-based medicines, in properly selected and supervised patients, as part of a multidisciplinary approach.