The five pillars of pain management

SUMMARY The last 10-15 years have seen an increase in the use of opioids in chronic noncancer pain. The consequences of increased use only gradually became apparent. The five pillars of pain management were developed as a convenient mechanism for the management of chronic noncancer pain and to allow for a comprehensive approach to patient care. The mnemonic ADDOP was developed: 'A' pillar one - assessment including risk and symptom assessment; 'D' pillar two - defining and treating the underlying condition; 'D' pillar three - making a pain diagnosis and going down an established path of treatment; 'O' pillar four - other treatments embracing the biopsychosocial model and treating co-morbidities; 'P' pillar five - patient self-management, personal responsibility and patient education. Adopting this method will prevent the practitioner and the patient from being drowned in the 'swamp of pain management'. If in doubt, the five pillars should be revisited and reviewed in any patient in which problems arise. This article is a commentary based on the author's clinical experience and observations. The recommendations and generalizations are not based on a systemic review of controlled trials. The article adds to the research-based recommendations that have already been published (i.e., the 2010 Canadian guidelines) by highlighting some of the issues and events surrounding the use of opioids for chronic noncancer pain and the thinking that went into the need to develop such guidelines. However, the Canadian Guidelines address the opiate issue only. They do not look at other aspects of pain management. By contrast, the five pillars of pain management provides a framework for the use of other modalities, other medications and other nonpharmacologic treatment, and self-management techniques. The five pillars represent a counterpoint, and emphasizes the need for risk assessment and a multipronged, holistic approach to the patient with chronic pain.