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Chronic pain; Law 38/2010; Opioid prescription; Opioids, Pain medicine; Physiotherapy; Rehabilitation

Commentary

For over a decade, a law has been in place in Italy that makes the prescription of opioid drugs less cumbersome than in the past, thus offering a feasible treatment to patients with chronic pain (Law 38/2010) [1]. This new regulation has radically changed the way pain is managed and treated in hospitals and outpatient facilities [2]. Firstly, the law requires health professionals to include pain assessment in every clinical documentation, using validated assessments (e.g. the Numeric Rating Scale [NRS] or the Visual/Analog Rating Scale [VAS]). Secondly, it aligned the prescription of opioids with the same rules as all other drugs or treatments (excluding injectables), facilitating the prescribing process more so than in the past. Therefore, following the introduction of the new legislation, more patients have the possibility to access opioid therapies for painkilling purposes [3].

However, despite these new rules, pain medicine specialists state that the number of opioid prescriptions has not radically changed. Unlike other areas of the world, which are experiencing the health and social consequences of opioid over-prescribing [4-12], the situation in Italy seems to be the opposite. This fact is confirmed by the sales volume of opioid drugs in Italy, as stated by the OsMed reports, which are the main pharmacological tools available to pain physicians [13]. Such sales show a minimal increase in the number of opioid prescriptions over time, which are still much lower than the average for Organization for Economic Cooperation and Development (OECD) countries [14]. Similar differences have been observed with regard to the number of patients treated by pain therapy networks. The considerable efforts made by scientific societies and institutions up to now have failed to create a culture of pain medicine awareness among Italians, especially when it comes to non-cancer pain or palliative care.

One possible reason for this, in our opinion, may be the fact that patients perceive the following potential sequence of events:

Chronic pain → opioid drugs → serious adverse effects → increased risk of drug addiction → increased risk of death.

The perceived risk associated with opioid prescriptions may discourage patients from undergoing pain medication evaluations, which can affect their recovery across a wide range of diseases. For instance, the most widespread algological pathology, sciatic pain, often leads to patients requiring long-term challenging physical and manual therapies, which do not always guarantee desirable results, simply because the associated pain is too strong for the patient to bear. In line with Occam’s razor, perhaps the most suitable solution is the simplest one. In other words, a greater interaction between ‘pain medicine’ (and not ‘pain therapy’ which fails to encapsulate the diagnostic aspects of treatment) and rehabilitation is required. In this scenario, opioid-based drugs may become a strategic support tool that allows the patient to undergo rehabilitation activities with little or no pain. A greater interaction between such concepts could change the aforementioned negative sequence of events, leading it towards the following sequence:

Chronic pain → need to restore function → need for treatments (including opioids) to minimize the time required to undertake rehabilitation (physical/manual treatments or infiltrative therapies) → minimal risk of adverse effects and addiction, with high benefits.

Such an approach would also allow the patients’ progress to be measured objectively. Indeed, physiotherapy as a clinical science has made enormous steps towards non-invasive joint kinematic analysis.

Now, it is possible to build and monitor, with precise numbers, the rehabilitation paths of patients using pain assessment questionnaires that usually are associated with high rates of subjectivity [15, 16].

Conclusion

In conclusion, we strongly believe that there is a need to raise awareness about the positive synergy that exists between pain medicine and rehabilitation among Italians. In this scenario, while undertaking rehabilitation, the appropriate use of opioid-based drugs may serve as a strategic treatment tool, with manageable adverse effects and a low risk of addiction.

Acknowledgement

We thank Ray Hill, an independent medical writer, who provided English-language editing and journal styling prior to submission on behalf of Springer Healthcare. This editorial assistance was funded by Sandoz.

Conflict of Interest

The authors report no conflicts of interest for this work.

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