Transition from acute to chronic pain: where cells, systems and society meet

Practice points

• Many people with chronic pain attribute it to an antecedent event: a work injury, accident, surgery or a medical illness.
• Given the difficulties treating chronic pain, there is increasing interest in trying to prevent acute pain episodes becoming chronic.
• While there are still many unanswered questions, there is an emerging body of evidence of the risk factors for chronicity and how to modify them.
• Biomedical factors, for example, the type of tissue damage, genetic vulnerability, are important but are often not modifiable.
• Effective management of acute pain is an important goal but does not necessarily prevent chronicity occurring.
• Psychosocial factors are increasingly recognized as important and may be modifiable even before the antecedent event, if it is predictable (e.g., before elective surgery or before commencing neurotoxic chemotherapy). If the event is unpredictable, intervention can be commenced early (e.g., after first recurrence of back pain).
• Modifiable psychosocial factors include attitudes and beliefs about pain, mood, social support, workplace issues. Others are not (e.g., age, gender, culture, personality).
• Validated tools are being developed for quantifying risk, enabling pre-emptive pain management to be more personalized.
• There is increasing evidence for early psychosocial intervention, for example, cognitive behavioral therapy for preventing the transition of acute low back pain and postsurgical pain.
• Internet-based delivery of these techniques holds promise for overcoming barriers to accessing practitioners who can teach these techniques.
• Clinicians need to be aware that what they say (e.g., overly solicitous comments about pain distress; endorsing sick leave) and do (ordering unnecessary tests; over prescribing medications; providing long-term treatment) may promote the transition to chronic pain.

Chronic pain is a major problem in society. It is estimated to affect 20% of the population(1) and more than one in three people aged over 65years. Approximately a third of those with chronic pain are disabled by it, so that it is one the leading causes of years lived with disability (2). Chronic pain is estimated to cost the economy billions of dollars annually, in direct medical costs as well as lost productivity (3).

Opioids have been the mainstay of treatment of chronic pain during the past 20-30years, but have now been shown to have limited efficacy that is outweighed by the harms (4). Many nonpharmacological approaches have been tried...