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The 3rd Asia Pacific Symposium on Pain Control, Singapore, September 1–3, 2006: Introduction and Overview
European Journal of Pain Supplements 1 (2007) ix–x www.EuropeanJournalPain.com
Preface
The 3rd Asia Pacific Symposium on Pain Control, Singapore, September 1–3, 2006: Introduction and Overview Marco Ermini Chairman of the Organizing Committee, Mundipharma Pte Ltd, Singapore
The First Asia Pacific Symposium on Pain Control (APSPC) was held in 1991 in Sydney Australia, with the intention of providing the Asia Pacific region with an international platform for discussing emerging concepts in cancer pain management with special regard to oral controlled release morphine. The Proceedings were published in the Postgraduate Medical Journal, Vol. 67, S2, 1991. Ten years later followed the 2nd APSPC, also in Sydney and equally successful, with a timely update on further developments in chronic pain management, and with the newly introduced controlled release oxycodone tablets as a novelty in the armamentarium of strong oral opioid analgesics. Proceedings were published in the European Journal of Pain, Vol. 5, SA, 2001. Since 2001 Mundipharma and other companies have progressed considerably with new forms of oral controlled release morphine preparations as well as with a number of new opioid products, some still in development, some already on the market. Among the latter, obviously, are the most successful oxycodone preparations, but also the tramadol and the hydromorphone controlled release preparations as well as the various opioid transdermal delivery systems. In parallel, the field of palliative care has grown enormously and along with it the acceptance of chronic pain management with opioid analgesics. As one of the consequences an increasing number of countries admitted strong opioids also for use in chronic non-cancer pain. In view of these important developments which also extended to most countries of the Asia Pacific Region it appeared appropriate to hold the 3rd APSPC 2006 in Singapore. I would like to acknowledge here the kind hospitality and support of our local colleagues before and during the symposium. Special thanks go to the Symposium Chairperson, Dr Cynthia Goh of the National Cancer Centre at Singapore, for her great commitment to the conference.
The Proceedings in hand contain the papers and posters presented during the 3rd APSPC. As the reader will see the topics pertain to a great extent to the situation in the Asia Pacific Region, thus honouring the name of the conference. In the following short preview I would like to illustrate this.
Treatment of pain in Asia In her overview Chairperson Cynthia Goh addresses the problem of pain in the Asia Pacific Region. She emphasizes the need of education in order to overcome the still prevailing myths and unjustified fears about morphine and other opioid analgesics. Furthermore infrastructure in the form of pain services and palliative care services needs to be built in hospitals, clinics, and the community. From the Philippines Francis Javier (Quezon City) reports that although there is adequate knowledge about the WHO analgesic ladder, resistance to prescribe strong opioids is still considerable. Although a certain increase in opioid prescriptions can be observed, especially for morphine and oxycodone, barriers to opioid use still persist twenty years after the WHO guidelines. Sang Chul Lee (Seoul) has a more encouraging view of the situation of pain control in Korea where the management of cancer pain is receiving increased attention from healthcare professionals who increasingly are becoming aware that there is no reason for these patients to have ongoing pain with the drugs and strategies currently available. Good news from China where the government encourages the treatment of cancer pain with effective opioid analgesics as Wei Lui (Beijing) reports. This manifests from the adjusted national narcotics control policy, including approval of new opioid analgesics, their increased manufacture and distribution throughout the country, and easier availability in hospitals.
1754-3207/$32 © 2007 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved.
x
Preface / European Journal of Pain Supplements 1 (2007) ix–x
Hospital-based palliative care teams (HPCTs) were introduced in Japan at general hospitals in 2002. Hideno Takahashi (Tokyo) reports that HPCTs are now required to cover overall cancer care rather than just the terminal phase. He also mentions the now available opioid analgesics and points out that education on cancer pain management has improved during the last 5 years.
pharmacological qualities, which make it a first-choice opioid for the treatment of acute and chronic pain. In addition, recent transdermal patches provide high-level patient acceptability, compliance and improved quality of life.
Safety and tolerability of opioid analgesics Chronic pain control with oxycodone and other strong opioids With the growth of the geriatric population the prevalence of neuropathic pain is increasing due to pain syndromes such as diabetic neuropathy and postherpetic neuralgia. Dwight Moulin (London, Ontario) reports on a recent systematic review of high-quality randomized controlled trials in the treatment of chronic neuropathic pain, including both non-opioid and opioid analgesics. Trials of controlled-release oxycodone in painful diabetic neuropathy showed consistent improvements in pain, sleep and ability to function. For these clinical findings Tsutomu Suzuki (Tokyo, Japan) provides a pharmacological rationale from comparative studies with rodents in a neuropathic pain-like state. Seong Ho Kim (Nam-Gu Daegu, South Korea) presents a study on the efficacy and safety of oxycodone administration to patients with intractable chronic, non-cancer pain. Over 50% pain relief was achieved in over half of the patients. There were no addiction problems observed and side effects were neither frequent nor life-threatening. Kazushige Murakawa (Hyogo, Japan) reports that in Japan oxycodone is substituting for morphine when CNSrelated side effects become evident. Also, good pain control in difficult cases may be achieved by a combination of opioid and nerve block therapy. In China, in a large combined multicenter trial the efficacy and safety of controlled release oxycodone in relieving moderate to severe non-cancer pain was studied. As reports Yuguang Huang (Beijing, China) onset of pain relief was achieved in most patients within 1 hour of drug administration. Controlled release oxycodone also significantly reduced the need for concomitant medications and showed a good safety profile. Michiteru Ohtani (Tokyo, Japan) describes buprenorphine and its active metabolite, norbuprenorphine. He suggests that the reason for the low risk of respiratory depression with chronic administration of buprenoprhine are the low plasma levels of norbuprenorphine. Marc Russo (Broadmeadow, NSW, Australia) considers buprenorphine to offer unique physico-chemical and
Norberto Francisco (Quezon City, Philippines) states that major post operative and post traumatic pain relief is impossible without opioid treatment. The risk of respiratory depression can be minimized by monitoring the degree of sedation, breathing, pupillary constriction, and gas exchange.
The creation of algorithms for the selection of opioids and other future developments Instruments to predict individual clinical pain and the responsiveness to analgesics should increase the efficacy and tolerability of analgesic treatments, and improve the overall treatment outcome. Clive Wilder-Smith (Berne, Switzerland) states that prediction of analgesia using quantitative sensory tests has been studied with some success. Dr Arendt-Nielsen suggests that using multi-modal, multi-tissue approach, new and existing analgesic drugs can be profiled. He argues that human experimental pain models could bridge animal and clinical pain research and provide new possibilities for designing successful and less expensive clinical trials. Julia Riley (London, England) proposes adding two additional steps to the classic WHO three step analgesic ladder to build, instead, a five step ladder. ‘Opioid switching’ should be step 4, with both pain and side effects as criteria. The 5th step finally should be anaesthetic intervention.
Posters Furthermore, a special section is devoted to the numerous posters from Japan and China with additional information and clinical observations both on pain management issues and opioid use in specific patient groups. I would not like to end without expressing my sincere thanks to the sponsoring Mundipharma companies, the local congress organizers and especially, all the roughly 150 participants from 15 countries who came to Singapore to attend the 3rd APSPC!
Preface
The 3rd Asia Pacific Symposium on Pain Control, Singapore, September 1–3, 2006: Introduction and Overview Marco Ermini Chairman of the Organizing Committee, Mundipharma Pte Ltd, Singapore
The First Asia Pacific Symposium on Pain Control (APSPC) was held in 1991 in Sydney Australia, with the intention of providing the Asia Pacific region with an international platform for discussing emerging concepts in cancer pain management with special regard to oral controlled release morphine. The Proceedings were published in the Postgraduate Medical Journal, Vol. 67, S2, 1991. Ten years later followed the 2nd APSPC, also in Sydney and equally successful, with a timely update on further developments in chronic pain management, and with the newly introduced controlled release oxycodone tablets as a novelty in the armamentarium of strong oral opioid analgesics. Proceedings were published in the European Journal of Pain, Vol. 5, SA, 2001. Since 2001 Mundipharma and other companies have progressed considerably with new forms of oral controlled release morphine preparations as well as with a number of new opioid products, some still in development, some already on the market. Among the latter, obviously, are the most successful oxycodone preparations, but also the tramadol and the hydromorphone controlled release preparations as well as the various opioid transdermal delivery systems. In parallel, the field of palliative care has grown enormously and along with it the acceptance of chronic pain management with opioid analgesics. As one of the consequences an increasing number of countries admitted strong opioids also for use in chronic non-cancer pain. In view of these important developments which also extended to most countries of the Asia Pacific Region it appeared appropriate to hold the 3rd APSPC 2006 in Singapore. I would like to acknowledge here the kind hospitality and support of our local colleagues before and during the symposium. Special thanks go to the Symposium Chairperson, Dr Cynthia Goh of the National Cancer Centre at Singapore, for her great commitment to the conference.
The Proceedings in hand contain the papers and posters presented during the 3rd APSPC. As the reader will see the topics pertain to a great extent to the situation in the Asia Pacific Region, thus honouring the name of the conference. In the following short preview I would like to illustrate this.
Treatment of pain in Asia In her overview Chairperson Cynthia Goh addresses the problem of pain in the Asia Pacific Region. She emphasizes the need of education in order to overcome the still prevailing myths and unjustified fears about morphine and other opioid analgesics. Furthermore infrastructure in the form of pain services and palliative care services needs to be built in hospitals, clinics, and the community. From the Philippines Francis Javier (Quezon City) reports that although there is adequate knowledge about the WHO analgesic ladder, resistance to prescribe strong opioids is still considerable. Although a certain increase in opioid prescriptions can be observed, especially for morphine and oxycodone, barriers to opioid use still persist twenty years after the WHO guidelines. Sang Chul Lee (Seoul) has a more encouraging view of the situation of pain control in Korea where the management of cancer pain is receiving increased attention from healthcare professionals who increasingly are becoming aware that there is no reason for these patients to have ongoing pain with the drugs and strategies currently available. Good news from China where the government encourages the treatment of cancer pain with effective opioid analgesics as Wei Lui (Beijing) reports. This manifests from the adjusted national narcotics control policy, including approval of new opioid analgesics, their increased manufacture and distribution throughout the country, and easier availability in hospitals.
1754-3207/$32 © 2007 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved.
x
Preface / European Journal of Pain Supplements 1 (2007) ix–x
Hospital-based palliative care teams (HPCTs) were introduced in Japan at general hospitals in 2002. Hideno Takahashi (Tokyo) reports that HPCTs are now required to cover overall cancer care rather than just the terminal phase. He also mentions the now available opioid analgesics and points out that education on cancer pain management has improved during the last 5 years.
pharmacological qualities, which make it a first-choice opioid for the treatment of acute and chronic pain. In addition, recent transdermal patches provide high-level patient acceptability, compliance and improved quality of life.
Safety and tolerability of opioid analgesics Chronic pain control with oxycodone and other strong opioids With the growth of the geriatric population the prevalence of neuropathic pain is increasing due to pain syndromes such as diabetic neuropathy and postherpetic neuralgia. Dwight Moulin (London, Ontario) reports on a recent systematic review of high-quality randomized controlled trials in the treatment of chronic neuropathic pain, including both non-opioid and opioid analgesics. Trials of controlled-release oxycodone in painful diabetic neuropathy showed consistent improvements in pain, sleep and ability to function. For these clinical findings Tsutomu Suzuki (Tokyo, Japan) provides a pharmacological rationale from comparative studies with rodents in a neuropathic pain-like state. Seong Ho Kim (Nam-Gu Daegu, South Korea) presents a study on the efficacy and safety of oxycodone administration to patients with intractable chronic, non-cancer pain. Over 50% pain relief was achieved in over half of the patients. There were no addiction problems observed and side effects were neither frequent nor life-threatening. Kazushige Murakawa (Hyogo, Japan) reports that in Japan oxycodone is substituting for morphine when CNSrelated side effects become evident. Also, good pain control in difficult cases may be achieved by a combination of opioid and nerve block therapy. In China, in a large combined multicenter trial the efficacy and safety of controlled release oxycodone in relieving moderate to severe non-cancer pain was studied. As reports Yuguang Huang (Beijing, China) onset of pain relief was achieved in most patients within 1 hour of drug administration. Controlled release oxycodone also significantly reduced the need for concomitant medications and showed a good safety profile. Michiteru Ohtani (Tokyo, Japan) describes buprenorphine and its active metabolite, norbuprenorphine. He suggests that the reason for the low risk of respiratory depression with chronic administration of buprenoprhine are the low plasma levels of norbuprenorphine. Marc Russo (Broadmeadow, NSW, Australia) considers buprenorphine to offer unique physico-chemical and
Norberto Francisco (Quezon City, Philippines) states that major post operative and post traumatic pain relief is impossible without opioid treatment. The risk of respiratory depression can be minimized by monitoring the degree of sedation, breathing, pupillary constriction, and gas exchange.
The creation of algorithms for the selection of opioids and other future developments Instruments to predict individual clinical pain and the responsiveness to analgesics should increase the efficacy and tolerability of analgesic treatments, and improve the overall treatment outcome. Clive Wilder-Smith (Berne, Switzerland) states that prediction of analgesia using quantitative sensory tests has been studied with some success. Dr Arendt-Nielsen suggests that using multi-modal, multi-tissue approach, new and existing analgesic drugs can be profiled. He argues that human experimental pain models could bridge animal and clinical pain research and provide new possibilities for designing successful and less expensive clinical trials. Julia Riley (London, England) proposes adding two additional steps to the classic WHO three step analgesic ladder to build, instead, a five step ladder. ‘Opioid switching’ should be step 4, with both pain and side effects as criteria. The 5th step finally should be anaesthetic intervention.
Posters Furthermore, a special section is devoted to the numerous posters from Japan and China with additional information and clinical observations both on pain management issues and opioid use in specific patient groups. I would not like to end without expressing my sincere thanks to the sponsoring Mundipharma companies, the local congress organizers and especially, all the roughly 150 participants from 15 countries who came to Singapore to attend the 3rd APSPC!