Insufficient pain relief – chronic pain

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Insufficient pain relief in chronic pain — what can be done?
This website is designed for healthcare professionals. Patients with chronic pain seeking treatment advice should speak to a doctor, and may also wish to access the patient resources that are freely available on the CHANGE PAIN® website
* representative of a typical patient, for illustrative purposes only

Kathy is one of many sufferers of chronic pain to endure insufficient pain relief1.

Learn what can you do to improve analgesia without increasing NSAID dose in patients with chronic pain

In Europe, a survey found that 40% of patients with chronic pain suffer from insufficient pain relief1, and a greater number (64%) experience insufficient pain relief “at times” — with as many as 79% enduring pain during activity1. Proportions varied in different European countries, perhaps as a result of variation in pain management approaches and pain medicine preferences.

Find out more about insufficient pain relief in Europe and the role of weak opioids in improving analgesia
Map of Italy

41% of patients with chronic pain surveyed in Italy reported insufficient pain relief1

Map of Belgium

61% of patients with chronic pain surveyed in Belgium reported insufficient pain relief1

NSAIDs are the most commonly prescribed medication for chronic pain in Europe1, but insufficient pain relief remains high1

Insufficient pain relief remains a problem for many patients receiving NSAIDs1. Some patients with chronic pain report that doctors can sometimes prioritise the treatment of their condition, such as inflammation, over ensuring adequate analgesia1. Adding on a weak opioid to NSAID treatment can be effective in the treatment of pain as demonstrated in OA flare pain and knee OA pain3,4.

Find out more about adding a weak opioid to NSAIDs to improve analgesia

  • 76% of European patients with chronic pain are prescribed NSAIDs2
  • 70% of European patients receiving NSAIDs for chronic pain need to change treatments because of insufficient pain relief2

Find out about tools that help your patient to describe the nature of their chronic pain in order to decide for the right pain management approach


Tools to help a patient explain pain, pain relief and pain medication side effects can help a physician understand each patient’s individual needs for pain management5. Is Kathy’s pain nociceptive, neuropathic, or both? Would Kathy prefer to accept a higher level of pain while limiting side effects, or would she be willing to endure side effects to obtain improved pain relief?

Find out more about tools for understanding your patient’s type, level of pain and pain management preferences

How to balance analgesia and NSAID side effects in patients with chronic pain

Continuous use of NSAIDs in chronic pain can lead to poor GI tolerability and, in some cases, serious GI, CV or renal side effects6. For this reason, the European Medicines Agency caution that NSAID treatment should be “at the lowest effective dose for the shortest possible duration to control symptoms”7. As the elderly are at higher risk of GI, CV and renal adverse events, the American Geriatric Society recommends that NSAIDs should be “considered rarely, and with extreme caution, in highly selected individuals”8. Although PPIs (proton pump inhibitors) can be co-prescribed to improve GI tolerability, these drugs carry their own risks9,10 and the risks of CV or renal adverse events remain.

Find out more adding on a weak opioid in patients receiving NSAIDs with insufficient pain relief
Gastro-intestinal tract

Poor GI tolerability Risk of serious GI adverse events


Risk of serious CV/renal adverse events

Which therapy combination best treats chronic pain? Can a combination therapy with a weak opioid in combination with paracetamol help to improve the efficacy of analgesia?

Targeting different pain pathways may help to manage chronic pain11. The need for involvement of multiple pathways to treat accordingly in patients with chronic pain is now being recognized12. An example of treating multiple pain pathways is the use of a nonclassical opioids together with paracetamol11. Nonclassical opioids are thought to target other pain pathways in addition to the mµ opioid receptor13, and add-in paracetamol is thought to improve the analgesic efficacy of nonclassical opioids12. In patients with chronic pain that is associated with inflammation, the anti-inflammatory activity of NSAIDs can be combined with a nonclassical opioid (+ paracetamol) for pain relief that targets multiple pathways3,4. Improved analgesia with a combined treatment may also enable side effects to be reduced by using lower doses of individual agents compared with monotherapy as demonstrated for treatment of hip OA related pain11.

Find out more about using nonclassical opioids as part of a mechanism-based treatment approach to chronic pain

Targeting multiple pain pathways
for more successful analgesia


1. Breivik, H., Collett, B., Ventafridda, V., Cohen, R. & Gallacher, D. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain. European Journal of Pain 10 (2006) 287–333
2. Varrassi, G., Müller-Schwefe, G., Pergolizzi, J., Orónska, A., Morlion, B. , Mavrocordatos, P., Margarit, C., Mangas, C., Jaksch, W., Huygen, F., Collett, B., Berti, M., Aldington, D., Ahlbeck, K. Pharmacological treatment of chronic pain — the need for CHANGE. Current Medical Research and Opinion (2010) 26:5, 1231—1245
3. Park, K., Choi, JJ., Kim, W., Min, JK., Park, SH., Cho, CS. The efficacy of tramadol/acetaminophen combination tablets (Ultracet®) as add-on and maintenance therapy in knee osteoarthritis pain inadequately controlled by nonsteroidal anti–inflammatory drug (NSAID). Clin Rheumatol (2012) 31:317—323
4. Silverfield, J. C., Kamin, M., Wu, S.–C., Rosenthal, N. Tramadol/acetaminophen combination tablets for the treatment of osteoarthritis flare pain: a multicenter, outpatient, randomized, double-blind, placebo-controlled, parallel-group, add-on study. Clin Ther (2002) 24: 282–297
5. Müller-Schwefe, G., Jaksch, W. , Morlion B., Kalso, E., Schäfer, M., Coluzzi, F., Huygen, F., Kocot-Kepska, M., Mangas, AC., Margarit, C., Ahlbeck, K., Mavrocordatos, P., Alon, E., Collett, B., Aldington, D., Nicolaou, A., Pergolizzi, J., Varrassi, G. Make a CHANGE: optimising communication and pain management decisions. Current Medical Research and Opinion (2011) 27:2, 481–488
6. Ong, C.K.S., Lirk, P., Tan, C.H., Seymour, R.A. An Evidence–Based Update on Nonsteroidal Anti–Inflammatory Drugs. Clinical Medicine & Research (2007) 5:1,19–34
7. European Medicines Agency, Evaluation of Medicines for Human Use. Opinion of the committee for medicinal products for human use pursuant to article 5(3) of regulation (EC) No 726/2004, For nonselective non–steroidal anti–inflammatory drugs (NSAIDs). EMEA/CHMP/410051/2006; EMEA/H/A–5.3/800


8. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. Pain Med. 2009;10(6):1062–1083. doi:10.1111/j.1526–4637.2009.00699.x
9. Janarthanan, S., Ditah, I., Phil, M., Adler, D., Ehrinpreis, M. Clostridium difficile –Associated Diarrhea and Proton Pump Inhibitor Therapy: A Meta–Analysis. Am J Gastroenterol 107 (2012) 1001 – 1010
10. Khalili, H., Huang, S., Jacobson, B., Camargo, Jr C., Feskanich, Diane., Chan, A. Use of proton pump inhibitors and risk of hip fracture in relation to dietary and lifestyle factors: a prospective cohort study. BMJ (2012) 344 –372
11. Raffa, R. Pharmacological aspects of successful long–term analgesia. Clin. Rheumatol. (2006) 25: Suppl 1, S9–15
12. Pergolizzi, J., Paladini, A., Varrassi, G., Raffa, R.. Change Pain: Ever Evolving–An Update for 2016. Pain Ther (2016) 5:127–133
13. Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet. 2004;43(13):879–92