The role of patient-controlled analgesia in the management of chronic pain

Patient-controlled analgesia (PCA) is a mainstay for postoperative and acute in-hospital pain management. Its role in the chronic pain setting, for example for palliative care as well as the care of ambulatory patients with chronic pain syndromes, is not well defined. Acute PCA typically involves intravenous PCA using morphine, although other opioid analgesics may be used. Chronic PCA may take advantage of emerging PCA technologies including transmucosal and transdermal delivery systems, novel dispensing units for oral tablets, and device-based therapies including implantable systems and external transcranial stimulation devices. Of particular concern in defining and developing chronic PCA systems are safety issues and concerns relating to long-term opioid therapy, whether administered via PCA or in oral form by prescription. Since chronic pain populations are diverse, chronic PCA solutions-if appropriate at all-may vary. Chronic PCA has been studied in palliative care cancer patients, but other groups who might benefit from chronic PCA are less thoroughly investigated. Aim: This paper reviews the concept of the use of PCA as an option for the management of chronic pain in an appropriate patient population. It does so from the point of view of medical need, i.e., the optimal management of pain. We fully recognize, however, that there are also potential negatives and consequences that could arise from the point of view of misuse, abuse, and diversion. It is our hope that this paper stimulates not only a discussion of the use of PCA for chronic pain patients, but also a discussion about how best to balance medical need vs. inappropriate use.