EFIC Position and Opinion Papers
The European Pain Federation EFIC convenes independent experts to develop scientific position papers, opinion papers, clinical practice recommendations and standards for the management of pain. You will find recent papers below.
Joint European Academy of Neurology-European Pain Federation-Neuropathic Pain Special Interest Group of the International Association for the Study of Pain guidelines on neuropathic pain assessment
In these guidelines, we aimed to develop evidence-based recommendations for the use of screening questionnaires and diagnostic tests in patients with neuropathic pain (NeP).
We systematically reviewed studies providing information on the sensitivity and specificity of screening questionnaires, and quantitative sensory testing, neurophysiology, skin biopsy, and corneal confocal microscopy. We also analysed how functional neuroimaging, peripheral nerve blocks, and genetic testing might provide useful information in diagnosing NeP.
Of the screening questionnaires, Douleur Neuropathique en 4 Questions (DN4), I-DN4 (self-administered DN4), and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) received a strong recommendation, and S-LANSS (self-administered LANSS) and PainDETECT weak recommendations for their use in the diagnostic pathway for patients with possible NeP. We devised a strong recommendation for the use of skin biopsy and a weak recommendation for quantitative sensory testing and nociceptive evoked potentials in the NeP diagnosis. Trigeminal reflex testing received a strong recommendation in diagnosing secondary trigeminal neuralgia. Although many studies support the usefulness of corneal confocal microscopy in diagnosing peripheral neuropathy, no study specifically investigated the diagnostic accuracy of this technique in patients with NeP. Functional neuroimaging and peripheral nerve blocks are helpful in disclosing pathophysiology and/or predicting outcomes, but current literature does not support their use for diagnosing NeP. Genetic testing may be considered at specialist centres, in selected cases.
These recommendations provide evidence-based clinical practice guidelines for NeP diagnosis. Due to the poor-to-moderate quality of evidence identified by this review, future large-scale, well-designed, multicentre studies assessing the accuracy of diagnostic tests for NeP are needed.
European clinical practice recommendations on opioids – Part 1: Role of opioids in the management of chronic noncancer pain
Opioid use for chronic non‐cancer pain (CNCP) is complex. In the absence of pan‐European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).
The clinical practice recommendations were developed by eight scientific societies and one patient self‐help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence‐based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case‐series, case‐control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.
The key clinical practice recommendations suggest: (a) first optimizing established non‐pharmacological treatments and non‐opioid analgesics and (b) considering opioid treatment if established non‐pharmacological treatments or non‐opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence‐ and clinical consensus‐based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation.
Opioids remain a treatment option for some selected patients with CNCP under careful surveillance.
Opioids should neither be embraced as a cure‐all nor shunned as universally dangerous and inappropriate for chronic noncancer pain. They should only be used for some selected chronic noncancer pain syndromes if established non‐pharmacological and pharmacological treatment options have failed in supervised pain patients as part of a comprehensive, multi‐modal, multi‐disciplinary approach to treatment. In this context alone, opioid therapy can be a useful tool in achieving and maintaining an optimal level of pain control in some patients.
Please find below a summary of the recommendations in other European languages. Please note that the accuracy of the translation is the responsibility of the translators. We are looking for volunteers to help us disseminate this vital information even further – find out more here.
European clinical practice recommendations on opioids – Part 2: Special situations
Opioid use for chronic non‐cancer pain (CNCP) is under debate. In the absence of pan‐European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).
The clinical practice recommendations were developed by eight scientific societies and one patient self‐help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence‐based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case‐series, case–control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.
The European Clinical Practice Recommendations give guidance for combination with other medications, the management of frequent (e.g. nausea, constipation) and rare (e.g. hyperalgesia) side effects, for special clinical populations (e.g. children and adolescents, pregnancy) and for special situations (e.g. liver cirrhosis).
If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively.
If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively. A collaboration of medical specialties and of all health care professionals is needed for some special populations and clinical situations.
Challenges and Opportunities in Translational Pain Research
For decades, basic research on the underlying mechanisms of nociception has held promise to translate into efficacious treatments for patients with pain. Despite great improvement in the understanding of pain physiology and pathophysiology, translation to novel, effective treatments for acute and chronic pain has however been limited, and they remain an unmet medical need. In this opinion paper bringing together pain researchers from very different disciplines, the opportunities and challenges of translational pain research are discussed. The many factors that may prevent the successful translation of bench observations into useful and effective clinical applications are reviewed, including interspecies differences, limited validity of currently available preclinical disease models of pain, and limitations of currently used methods to assess nociception and pain in non‐human and human models of pain. Many paths are explored to address these issues, including the backward translation of observations made in patients and human volunteers into new disease models that are more clinically relevant, improved generalization by taking into account age and sex differences, and the integration of psychobiology into translational pain research. Finally, it is argued that preclinical and clinical stages of developing new treatments for pain can be improved by better preclinical models of pathological pain conditions alongside revised methods to assess treatment‐induced effects on nociception in human and non‐human animals.
For decades, basic research of the underlying mechanisms of nociception has held promise to translate into efficacious treatments for patients with pain. Despite great improvement in the understanding of pain physiology and pathophysiology, translation to novel, effective treatments for acute and chronic pain has however been limited, and they remain an unmet medical need.
Read the full paper here: https://onlinelibrary.wiley.com/doi/full/10.1002/ejp.1730
Video Interview with Authos
Watch a interview on the paper with the authors here:
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
The European Pain Federation EFIC is excited to present CRPS Assist, a web-based application for physiotherapists. The website aims to help in diagnosing and treating patients with Complex regional pain syndrome.
Standards for the management of cancer‐related pain across Europe
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.
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
Public interest in the use of cannabis products for medical purposes in Europe has been accelerated by advocacy and by the legalization of marijuana for recreational and medical use by lay organizations and political parties (Health Products Regulatory Authority, 2017). Some European governments have sanctioned and legalized herbal cannabis for medicinal use for a wide range of potential indications, including chronic pain management, and in so doing have abandoned the due diligence process required to ensure efficacy and safety (Häuser, Petzke, & Fitzcharles, 2018). A recent survey conducted by the European Pain Federation EFIC found striking differences between European countries in (a) the availability of plant‐derived and synthetic cannabinoids, (b) the use of medical cannabis for pain management and for symptom control in palliative care and (c) the covering of costs by health insurance companies or state social security systems (Krcevski‐Skvarc, Wells, & Häuser, 2018). Systematic reviews have come to partially divergent conclusions on the efficacy and safety of cannabis‐based medicines for chronic pain. Some national guidelines and expert groups have given different recommendations on the role of cannabis‐based medicines for some pain syndromes such as neuropathic pain and fibromyalgia (Häuser et al., 2018).
Therefore, the pain community has the responsibility to examine the currently available evidence so as to competently advise and inform other jurisdictions, healthcare workers, patients and their relatives about the role and the responsible use of cannabis‐based medicines for chronic pain management. Our recommendations are intended for primary care physicians who are confronted with the desire of patients for a prescription of cannabis‐based medicines, and for specialist prescribers.
This position paper was produced by a task force (TF) of the European Pain Federation (EFIC) in order to provide a fair, balanced and evidence‐based summary of the role of cannabis‐based medicines for use in pain management. The recommendations summarize the relevant data where such exist. Where data are lacking, the recommendations presented reflect the clinical experience of the TF.
We identified 15 systematic reviews (Andreae et al., 2015; Asbridge, Hayden, & Cartwright, 2012; Aviram & Samuelly‐Leichtag, 2017; Finnerup et al., 2015; Fitzcharles, Baerwald, Ablin, & Häuser, 2016; Häuser et al., 2018; Häuser et al., 2018; Martın‐Sanchez, Furukawa, Taylor, & Martin, 2009; Mücke et al., 2016; Mücke, Philipps, Radburch, Petzke, & Häuser, 2018; National Institute of Health, 2018; National Academies of Sciences, Engineering, and Medicine, 2017; Nugent et al., 2017; Petzke, Enax‐Krumova, & Häuser, 2016; Whiting et al., 2015) and five recommendations or guidelines of scientific societies and national agencies (Committee on Obstetric Practice, 2017; Kahan, Srivastava, Spithoff, & Bromley, 2014; National Board of California, 2017; The College of Family Physicians in Canada, 2018; Health Products Regulatory Agency, 2017). The reviews cover the same limited evidence. The first review on efficacy of cannabis‐based medicines for chronic pain was published in 2009 and the most recent in 2018. All systematic reviews found limited evidence on which to base any recommendations. Of the five guidelines / recommendations of scientific societies, the first was produced in year 2014 and the most recent in year 2018. Of the 37 countries in the European Pain Federation, none have produced a national guideline on the use of cannabis‐based medicines for chronic pain (Krcevski‐Skvarc et al., 2018).
We identified 55 recommendations from the review of both the existing other guidelines/recommendations and evidence summaries of systematic reviews. The topics of the position paper were selected based on the scientific and clinical experience of the authors (which issues are important for clinical practice?) and on the literature reviewed. For each recommendation of the EFIC position paper, we summarize the ‘key point(s)’ and provide a comment to capture the view of the panel.
This position paper provides expert recommendations for nonspecialist and specialist healthcare professionals in Europe, on the importance and the appropriate use of cannabis‐based medicines as part of a multidisciplinary approach to pain management, in properly selected and supervised patients.
Old position papers
Use of opioids for pain management
Poorly controlled pain is a global public health issue. The personal, familial and societal costs are immeasurable. Only a minority of European patients have access to a comprehensive specialist pain clinic. More commonly the responsibility for chronic pain management and initiating opioid therapy rests with the primary care physician and other non-specialist opioid prescribers. There is much confusing and conflicting information available to non-specialist prescribers regarding opioid therapy and a great deal of unjustified fear is generated. Opioid therapy should only be initiated by competent clinicians as part of a multi-faceted treatment programme in circumstances where more simple measures have failed. Throughout, all patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to yield the desired results and/or the patient is additionally burdened by an unacceptable level of adverse effects, the overall management strategy must be reviewed and revised. No responsible clinician will wish to pursue a failed treatment strategy or persist with an ineffective and burdensome treatment. In a considered attempt to empower and inform non-specialist opioid prescribers, EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper on appropriate opioid use in chronic pain. The expert panel reviewed the available literature and harnessed the experience of many years of clinical practice to produce these series of recommendations. Its success will be judged on the extent to which it contributes to an improved pain management experience for chronic pain patients across Europe.
This position paper provides expert recommendations for primary care physicians and other non- specialist healthcare professionals in Europe, particularly those who do not have ready access to specialists in pain medicine, on the safe and appropriate use of opioid medications as part of a multi-faceted approach to pain management, in properly selected and supervised patients.