EDITORIAL

Evidence-Based Pain Managementand Palliative Care

Pain remains the primary reason that patients seek medications andenter the health care system. And palliative care is among the most rap-idly growing components of American health care. Most clinicians stillsee pain and most symptom control as a primary care functions. But fewprimary care clinicians are trained to manage complex pain syndromes.There is a growing literature in both pain management and palliativecare; indeed it often overlaps. But pain and symptom management areoften driven more by normative practice and anecdote than evidence,per se. Now that evidence is becoming more available, that is not an ac-ceptable scenario.

It is easy to forget how recently palliative care was defined and begunas a focused type of practice. The modern hospice movement is gener-ally recognized as beginning with the opening of St. Christopher’s Hos-pice in London in 1967.1 The first American Hospice program beganless than five years later.2 But it was only in 1990 that the World HealthOrganization adopted the European Association for Palliative Care def-

Journal of Pain & Palliative Care Pharmacotherapy, Vol. 16(2) 2002 2002 by The Haworth Press, Inc. All rights reserved. 1

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inition of palliative care, i.e., active total care of patients whose diseaseis not responsive to curative treatment.2

Palliative care is becoming increasingly organized, largely throughthe efforts of the National Hospice and Palliative Care Organization(NHPCO), the American Academy of Hospice and Palliative Medicine,and the Association of Hospice and Palliative Care Nurses. Palliativecare is the principle focus of increasing numbers of physicians, nurses,pharmacists, psychosocial and spiritual care providers, and other healthprofessionals. Efforts to establish full specialty boards in both palliativemedicine and palliative pharmacy practice are underway, but the spe-cialty is currently recognized by neither the American Commission onGraduate Medical Education (ACGME) or the Board of PharmaceuticalSpecialties (BPS).

In 1997, the Institute of Medicine (IOM) of the American NationalAcademy of Sciences formally addressed palliative care in the report ofthe IOM Committee on Care at the End of Life.3 The conclusions of thatreport state, in part, that palliative care should become “if not a medicalspecialty, at least a defined area of expertise, education and research.”

One limitation of the short history of both pain management and pal-liative care as focused areas of practice is the relatively small literaturein the field. However, there are increasing numbers of published, welldesigned clinical and epidemiological studies that define optimal pharm-acotherapy in pain management and palliative care. Unfortunately,much of that work is not indexed in a manner that makes it readily re-trievable by clinicians. This Journal is attempting to help meet this needthrough a new feature containing annotated bibliographies of recentpublications on evidence-based pain management and palliative carethat is introduced in this issue. This feature is coordinated by PhillipWiffen, coordinating editor of the Pain, Palliative and Supportive CareCollaborative Review Group (PaPaS) of the International CochraneCollaboration. The Cochrane Collaboration is the largest and most wellrespected evidence-based medicine activity in the world. Registrationof PaPaS by Cochrane signifies the growth and relevance of evidence-based work in pain and palliative care. This issue also contains descrip-tion of PaPaS written by Wiffen and a review of his new book entitledEvidence-Based Pharmacy. Two other helpful resources are nowavailable. An annotated bibliography of drug therapy-related issuespublished in the biomedical literature on pain management and end-of-life care was complied by the Pain and Policy Studies Group of theUniversity of Wisconsin for the Robert Wood Johnson Foundation.It is available through the World Wide Web Last Acts site at

2 JOURNAL OF PAIN & PALLIATIVE CARE PHARMACOTHERAPY

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<www.lastacts.org>. Another resource is the book entitled Evidence-Based Symptom Control in Palliative Care: Systematic Reviews andValidated Clinical Practice Guidelines for 15 Common Problems inPatients with Life Limiting Disease.4 That book is an adaptation of twospecial issues of one of the predecessors of this Journal, the formerJournal of Pharmaceutical Care in Pain & Symptom Control.

Evidence-based medicine has been defined as the conscientious, ex-plicit and judicious use of current best evidence in making decisionsabout the care of individual patients.5 It is important to note that the de-velopers of the concept of evidence-based medicine opine that evidenceis to be integrated with the clinician’s knowledge and experience andpatient-specific factors in determining optimal therapy. Published evi-dence complements clinicians’ experience and judgment, it does not re-place them. When evidence and experience agree, good therapy is easyto define. In many areas of palliative care, sufficient evidence is justnow becoming available to allow us to make truly evidence-based clini-cal decisions. In others, evidence is contradictory, and in several areasevidence is lacking. When evidence is limited, or when it strongly con-tradicts one clinician’s experience, other clinicians’ published experi-ence becomes very useful in determining which clinical course is best.Arthur G. Lipman, PharmD

Arthur G. Lipman, PharmD, FASHPEditor

REFERENCES

1. Saunders C, Baines M. Living with Dying. Oxford, Oxford University Press,1983.

2. WHO Expert Committee. Cancer Pain Relief and Palliative Care. Technical Re-port Series 804. Geneva, World Health Organization, 1990.

3. Field MJ, Cassell CK, editors. Approaching Death: Improving Care at the End ofLife. Washington, DC, National Academy Press, 1997.

4. Lipman AG, Jackson KC, Tyler LS, editors. Evidence-Based Symptom Controlin Palliative Care: Systematic Reviews and Validated Clinical Practice Guidelines for15 Common Problems in Patients with Life Limiting Disease. Binghamton NY, Phar-maceutical Products Press, an imprint of The Haworth Press, Inc., 2000.

5. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evi-dence based medicine: What it is and what it isn’t. BMJ 1996;312:71-2.

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