Abstract
Introduction
Despite major progress in the diagnostic and therapeutic approaches to patients with endometriosis or other diseases leading to pelvic pain, treatment of pain is largely heterogeneous among specialists and based on different strategies (1).
Nowadays in Italy, the approach to patients with chronic and severe pain due to a variety of diseases, including malignancies and orthopedic and rheumatic diseases among others, has significantly evolved following the introduction of a national law (38/2010) that allows a more straightforward approach to the management of pain patients (2). In particular, this law relaxed restrictions on the use of opioids. These drugs are powerful and well tolerated (3, 4) and represent a valid alternative to commonly prescribed drugs, such as nonsteroidal antiinflammatory drugs (NSAIDs) and paracetamol, which are in general less effective than opioids and can lead to severe, yet often underestimated, side effects including cardiovascular and renal effects as well as acute hepatic failure (5).
On the other hands, the effects of opioids, especially at large doses, on alertness, and on gastroinstestinal motility, leading to constipation, led physicians to limit their use to selected cases, although data on the use of newer opioids in combination indicate the possibility to minimize the importance of theses side effects (6).
Methods
We administered a questionnaire to a group of gynecologists that focused on their current approach to pain in their endometriosis patient population, on their knowledge of the law 38/2010 and on their perception of the efficacy and of side effects of different therapeutic classes of medications, including NSAIDs, the newer coxibs, paracetamol (alone and in combination with codeine) and opioids.
Results
A total of 70 specialists (48 men, 22 women) whose mean age was 42.9 ± 11 years answered the questionnaire. Of these specialists, 56% were hospital-based, whereas 34% worked at academic centers and the remainder worked at centers of first referral. Different areas of Italy (northern, central, and southern) were appropriately represented by the sample. A series of questions regarding the approach to pain in patients with endometriosis in different settings during their clinical history (from diagnosis, to the implementation of hormonal therapy to the presurgery and postsurgery period, in those who need them) showed a striking prevalence of the use of standard NSAIDs in the treatment of pain (36% to 51% of cases, depending upon the clinical setting) followed by paracetamol (14% to 18%) and newer coxib compounds (4% to 6%), with the use of opioids limited to a minority of cases (range 0 to 8% of cases).
When asked about side effects, specialists seemed to be well aware of their incidence. The potential for side effects of NSAIDs at the gastrointestinal level was well-recognized by the majority of the specialists interviewed (61%), while the potential side effects of opioids (somnolence, etc) at the central nervous system level was indicated only by a minority of physicians (21%).
Finally, and most interestingly, only a minority of specialists indicated that they had even a fair knowledge of law 38/2010 (16%), while more than one third of the specialists interviewed (34%) candidly declared their lack of knowledge of the law.
Discussion
In conclusion, the data from this survey that focused specifically on the role of classic antalgic drugs and did not include questions regarding the efficacy of hormonal treatment on pain, suggest that the treatment of pain in patients with endometriosis in Italy still relies heavily on NSAIDs, which are used in the vast majority of patients. A major educational effort is required to increase the knowledge of the pivotal law 38/2010 among gynecologists and to promote a more thorough evaluation of the most appropriate treatment for pain in these patients.
Footnotes
Financial support: None.
Conflict of interest: None.