Page 342 Guide to Pain Management in Low-Resource Settings

330 Uriah Guevara-Lopez

Table 1
Defi nition of practice guidelines and other terms that are confused with practice guidelines
Concept Defi nition
Practice guidelines A systematically developed statement to assist practitioner and patient decisions about appropriate
health care for specifi c clinical circumstances. “Protocol” is often used interchangeably with “guideline,”
although some view “practice protocols” as a more specifi c (procedure- or specialty-specifi c) form of
practice guidelines.
Clinical pathways An optimal sequencing and timing of interventions for a particular diagnosis or procedure. A “care
map” or multidisciplinary action plan extends the concept of a clinical pathway by including an outcome
index, which allows for the evaluation of the interventions.
Clinical algorithms A more complex set of instructions containing conditional logic, usually expressed in branching trees.
Information extracted from: Henning [4].

diagnostic and therapeutic approaches are outdated Additionally, pain has a signifi cant impact on
meaning either impaired effi cacy or decreased safety. physical function and activity, return-to-work-quota,
Th e speed of medical evolution has complicated social and family relations as well as the general psy-
medical decision making; for that reason, PG may be choaff ective state of the aff ected patient. Th is may prove
used as an instrument to assist the clinician. Th is objec- to be a burden for the family of the patient, but also to
tive is possible because PG summarizes the collective ex- the society as a whole, since insuffi cient pain manage-
perience and establishes grades to scientifi c knowledge. ment is a major cause for increased use of health care
resources. Th erefore, health care policies need the im-
Are there diff erent types plementation of rationalized instruments that can op-
of practice guidelines? timize and improve the quality of medical attention for
the most relevant diseases including pain syndromes.
Attempts to regulate PG had been made since the early
1980s. Nowadays, diff erent types of practice guidelines How are practice guidelines
can be identifi ed: (i) for the diagnosis and management developed?
of specifi c clinical circumstances, (ii) for risk manage-
ment, (iii) for the improvement of quality systems, (iv) Th ere is a general agreement, that PG must be submit-
for medical regulation, (v) for education, and (vi) for ted to public scrutiny, revised regularly in response to
preventive care. medical advances, and derived from high quality scien-
tifi c evidence. PG must be easy to comprehend, inclu-
Why do we need practice guidelines sive, and manageable. Th e method for evidence selec-
for pain management? tion must be explained and the criteria used to grade
each recommendation must be explained.
Pain is considered a health problem in few countries, Protocols for developing guidelines have many
but the number of countries where pain management common features: (i) Reviews of existing research fi nd-
becomes a health care priority is increasing. Th e de- ings are conducted, often with the aid of the National
velopment of PG in pain medicine is supported by Library of Medicine. (ii) Studies are selected according
the following issues: (i) the number of surgical inter- to predetermined criteria and fi ndings are summarized
ventions is increasing in many low-resource countries using techniques such as meta-analysis or systematic
without any concept to control postoperative pain; (ii) reviews. (iii) Panels of experts are convened and guide-
the demographic change (increase of older population) lines are revised according to feedback received. (iv)
worldwide will be associated with a growing preva- Consensus is achieved in some areas; and where dis-
lence of cancer pain; (iii) the frequency of chronic non agreement or uncertainty remains and more research is
cancer pain is recognized more today, for which it has needed, the developers describe this defi ciency.
been estimated, that the annual treatment costs equal Strategies for developing PG have been pro-
or exceed exceeds those for coronary disease, cancer posed by diverse groups worldwide, a summary of those
and AIDS. is described in Table 2.