Vicious Circle


The pharmacological treatment of severe chronic pain is in many cases often inefficient. Patients are often not adequately treated and if they have access to potent substances the balance between sufficient pain relief and acceptable tolerability as well as tailoring the treatment to the pain is difficult to maintain.

But what makes treatment so complicated?

Insufficient analgesic efficacy which is accompanied by an acceptable tolerability leads to dose increases in order to achieve satisfactory pain relief. Due to dose-dependent efficacy of classical opioids, the dose increase may result in effective analgesia. However, at the same time it increases the dose-dependent risk of side-effects. When tolerability becomes unacceptable and/or side-effect attenuating medications (e.g., antiemetics against opioid-induced nausea and vomiting) do not show their desired effect, physicians or even patients themselves reduce the analgesic dose. Indeed, tolerability is improved - but inadequate analgesia is the unintentional consequence.


 Learn more about the Vicious Circle


The Vicious Circle starts rotating

The result of the Vicious Circle can either be side effects, lack of efficacy or analgesic tolerance which may all lead to treatment discontinuations and low compliance of patients.



Varrassi G et al. Pharmacological treatment of chronic pain - the need for CHANGE. Cur Med Res Opin, 2010, 26(5): 1231-1245.

Treatment Challenges

Reducing the risk of discontinuation

Dr Gerhard H.H. Müller-Schwefe
Balancing efficacy and side effects

Prof Eija Kalso


Vicious Circle Tool


The Vicious circle tool helps physicians finding the right balance between adequate pain relief and acceptable tolerability.

 Vicious Circle Tool


eCME Courses


CHANGE PAIN provides you with eCME courses – accredited by Union Européenne des Médecins Spécialistes (UEMS). 8 Modules, each accredited for 1 hour of participation.

 eCME Courses on the topic of pain