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News&Review No.3

6 Professor Eija Kalso THE VICIOUS CIRCLE IN CHRONIC PAIN TREATMENT: BALANCING BETWEEN EFFICACY AND ADVERSE EFFECTS COMMENTARY Professor Eija Kalso, President-elect of the International Association for the Study of Pain (IASP), Finland Clinical evidence has shown that the main reasons for treatment discontinuation are ad- verse effects, particularly in the beginning of the treatment, and lack of efficacy in the long-run. A severe pain patient trapped in the Vicious Circle therefore has to make a trade-off between harm and benefit. Increasing awareness of the Vicious Circle among physicians could improve pain management and reduce treatment discontinuation. I personally believe that it is important to motivate physicians attending the Expert Summit to establish CHANGE PAIN locally in order to reach those colleagues who were not able to participate at this meeting. In this way we can all help improve chronic pain management in Europe. Figure 2 Dose reduction Dose increase insufficient efficacy acceptable tolerability sufficient efficacy unacceptable tolerability The pharmacological treatment of severe chronic pain, particularly with classical opioids, is often inefficient because of the difficulty in maintain- ing a balance between analgesia and adverse effects. In routine clin- ical settings, 50% of chronic pain patients currently receive inade- quate pain relief1 and many discon- tinue treatment because of adverse effects2. This continuous burden to patients is described by the Vicious Circle3 (see Figure 2) in which the patient alternates between ade- quate pain relief but unacceptable side effects, and acceptable side ef- fects but inadequate pain relief, leading to poor compliance and treatment discontinuations. Once the Vicious Circle is established it treatment for the underlying pain mechanisms, interactions between co-administered drugs which can re- duce analgesic efficacy, or the de- velopment of analgesic tolerance. Withdrawal from the opioid treat- ment most frequently follows ad- verse effects rather than lack of efficacy, reducing patient’s quality of life and compliance with therapy3. In order to handle the limitations of today's treatment options and to im- prove pain management, physicians should treat adverse events, titrate pain medication carefully and be- sides consider non-pharmacological therapies and individual patient's needs. References 1. Galvez R. Variable use of opioid pharmacother- apy for chronic noncancer pain in Europe: causes and consequences. J Pain Palliat Care Pharmaco- therapy 2009, 23 (4): 346-356. 2. Kalso E et al. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain, 2004, 112:372–80. 3. Varrassi G et al. Pharmacological treatment of chronic pain – the need for CHANGE. Curr Med Res Opin, 2010, 26(5):1231-1245. will continue until a balance is achieved between sufficient analge- sia and acceptable tolerability3. Factors leading to the Vicious Circle include the wrong choice of drug