Fourth analgesic step

The “fourth analgesic step” refers to the advanced stage in pain management where non-traditional and interventional techniques are employed when conventional analgesics (such as opioids or non-opioids) fail to control pain effectively. This step is often used for managing complex or chronic pain conditions, particularly in cases of cancer pain or neuropathic pain, where standard pharmacological treatments are insufficient.

Some common interventions associated with the fourth analgesic step include:

Neurostimulation techniques (e.g., spinal cord stimulation) Intrathecal drug delivery systems (administering medications directly into the cerebrospinal fluid) Nerve blocks (injections of anesthetic near nerves to block pain signals) Palliative radiotherapy (used to alleviate pain caused by tumors) Surgical interventions (e.g., neurolysis, cordotomy) These interventions are considered after the failure of previous steps in the WHO analgesic ladder, which starts with non-opioids (Step 1), mild opioids (Step 2), and strong opioids (Step 3). The fourth step typically involves a multidisciplinary approach, addressing not only physical pain but also psychological and social aspects of the patient's well-being.

Intrathecal drug delivery (IDD) is part of the fourth analgesic step. Evidence on the quality of life of patients with refractory chronic non-cancer pain (CNCP) using these devices and their long-term outcomes is scarce. A study aimed to evaluate patients with IDD to assess their HRQoL. Additionally, the study seeks to understand the patients' satisfaction with the treatment and changes in pain magnitude over time. Adult patients with CNCP and intrathecal drug delivery systems (IDDS) were included. The study population was divided into two groups: less than and more than 15 years of treatment. HRQoL was analyzed using validated questionnaires. Pain reduction was assessed using the visual analog scale (VAS), and treatment satisfaction was evaluated using the Patient Global Impression of Improvement scale. Results: The results indicate a poor HRQoL in IDD patients, with better scores in the group with ≥15 years of treatment. Pain reduction was similar in both groups, and patients reported a positive satisfaction level with the treatment. HRQoL in CNCP patients is severely affected. Long-term IDD patients have a similar or even better HRQoL in some respects compared to those with shorter follow-ups. IDD patients experienced pain reduction, with most feeling better or much better ¹⁾.