Efficacy and CostEffectiveness Treatment

for Chronic Pain

What is pain?
Pain is a complex phenomenon, and the experience of pain is
unique for each individual. It has been described in many ways:
An unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such
damage.
(Classification of chronic pain. Descriptions of chronic pain syndromes
and definitions of pain terms. Prepared by the International
Association for the Study of Pain, Subcommittee on Taxonomy. Pain
1986 (Suppl 3): S1-226)
An experience that affects, and is affected by, both the mind and
the body. It involves the perception of a painful stimulus by the
nervous system and the reaction of a person to this.
(Stannard C and Booth S.(2004) Pain. Churchill Livingstone. 183-6)
Pain is what the patient says hurts.

Chronic Pain
Chronic pain - persists over weeks or months and
may be associated with significant changes in
lifestyle, functional ability and personality.
Management is challenging as it requires careful
assessment, not only of the nature and intensity
of pain, but also of the degree of psychological
distress.
It is a significant and costly problem,
(Doyle D et al.2004.Oxford Textbook of Palliative
Medicine 3rd ed: 299)

Cancer Pain
Cancer pain is often very complex, but the most intractable pain
is often neuropathic in origin, arising from tumour invasion of the
meninges, spinal cord and dura, nerve roots, plexuses and
peripheral nerves.
Multimodal therapies are necessary.
The management of cancer pain can and should be improved by
better collaboration between the disciplines of oncology, pain
medicine and palliative medicine. This must start in the training
programmes of doctors, but is also needed in established teams
in terms of funding, time for joint working and the education of all
healthcare professionals involved in the treatment of cancer pain.

(British Pain Societys. 2010. Cancer Pain Management. London :

The British Pain Society )

Cancer Pain

(British Pain Societys. 2010. Camcer Pain Management.

London : The British Pain Society )

Pain Ladder WHO

The 3-step analgesic ladder developed by the World Health

Organization. Reproduced by permission of WHO. Cancer Pain
Relief. Geneva:
WHO; 1986.
(Grisell Vargas-Schaffer. 2010. Is the WHO analgesic ladder still
valid?

Why we need new pain

management?
Previous data has shown the need for better cancer
pain management. UK Cancer Deaths numbered
153,397 in 2004 (UK National audit Office reports 2000,
2004). A conservative estimate has suggested that
10% fail to receive effective relief by WHO guidelines;
however, this is an underestimation given recent
surveys (EPIC 2007, Valeberg, 2008) which show that,
in reality, upwards of 30% of patients receive poor pain
control, especially in the last year of their lives.. Thirty
percent represents 46,020 patients failing per year.
(British Pain Societys. 2010. Cancer Pain Management.
London : The British Pain Society )

Pain Ladder - Modified

(Grisell Vargas-Schaffer. 2010. Is the WHO analgesic

ladder still valid?
Twenty-four years of experience. Canadian Family
Physician Le Mdecin de famille canadien Vol 56: june

Modified Pain Ladder

The adaptation of the analgesic ladder for acute pain, chronic noncancer pain,
and cancer pain is based on the same principles as the original ladder.
This revision integrates a fourth step and includes consideration of
neurosurgical procedures such as brain stimulators, Invasive techniques, such
as nerve blocks and neurolysis (eg, phenolization, alcoholization,
thermocoagulation, and radiofrequency are used at the fourth step. it can be
used for acute pain in emergency departments and in postoperative situations.
The new fourth step is recommended for the treatment of crises of chronic
pain. Interventional pain literature suggests that there is moderate evidence
for the use of transforaminal epidural steroid injections, lumbar percutaneous
adhesiolysis, and spinal endoscopy for painful lumbar radiculopathy, and
limited evidence for intradiscal treatments in low back pain.
Medullar and peripheral stimulators also have been included at the fourth level.

(Grisell Vargas-Schaffer. 2010. Is the WHO analgesic ladder still valid? Twentyfour years of experience. Canadian Family Physician Le Mdecin de famille
canadien Vol 56: june 2010)

 Cancer pain is amenable to various types of analgesic interventions.

While oral or transdermal opioids play the dominant role in controlling
pain in cancer patients, other options are available.
While increasing opioid doses may provide analgesia in most patients,
higher doses of opioids are often accompanied with undesirable side
effects.
The search for effective analgesia should include consideration of
interventional techniques. Numerous interventional options are readily
accessible and most can be performed on an outpatient basis.
They can be used as sole agents for the control of cancer pain or as
useful adjuncts to supplement analgesia provided by opioids while
decreasing opioid dose requirements and side effects.
(Rafael Miguel. 2000. Interventional Treatment of Cancer Pain: The Fourth
Step in the World Health Organization Analgesic Ladder. Cancer Control.
March/April 2000, Vol.7, No.2)

 Bruary March)

(Gatchel, et al.204. Interdisciplinary Chronic Pain Management.

American Physicologis February March )

Conclusion
Chronic pain management involving
multidisciplinary, multiple approach
and modalities could be more
beneficial and cost effective in long
term.

Thank You