This prospective randomized study aims to evaluate the feasibility and cost-effectiveness of combining transcranial direct current stimulation (tDCS) with patient controlled intravenous morphine analgesia (PCA-IV) as part of multimodal analgesia after thoracotomy. Patients assigned to the active treatment group (a-tDCS, n = 27) received tDCS over the left primary motor cortex for five days, whereas patients assigned to the control group (sham-tDCS, n = 28) received sham tDCS stimulations. All patients received postoperative PCA-IV morphine. For cost-effectiveness analysis we used data about total amount of PCA-IV morphine and maximum visual analog pain scale with cough (VASP-C_max). Direct costs of hospitalization were assumed as equal for both groups. Cost-effectiveness analysis was performed with the incremental cost-effectiveness ratio (ICER), expressed as the incremental cost (RSD or US$) per incremental gain in mm of VASP-C_max reduction. Calculated ICER was 510.87 RSD per VASP-C_max 1 mm reduction. Conversion on USA market (USA data 1.325 US$ for 1 mg of morphine) revealed ICER of 189.08 US$ or 18960.39 RSD/1 VASP-C_max 1 mm reduction. Cost-effectiveness expressed through ICER showed significant reduction of PCA-IV morphine costs in the tDCS group. Further investigation of tDCS benefits with regards to reduction of postoperative pain treatment costs should also include the long-term benefits of reduced morphine use.

Developing countries account to more than 80% of the world population. In the last two decades, the term 'developing countries' is used to group the countries that have not yet reached level of sophisticated industrialization like Western Europe and North America. In developing countries, acute postoperative pain management has special considerations. Barriers to implementing adequate acute postoperative pain management refer to health service organization, drug availability, inadequate education of pain management providers, as well as inadequate education of patients themselves and prejudices they may have regarding their postoperative pain and consequences if is inadequately treated. Health care workers in developing world are making effort to improve postoperative pain management. Serbia has been included in PAIN OUT European network initiative, with the aim to construct the bundle of simply applied measures and the effects of their implementation on postoperative pain treatment. So far, most of these measures refer to health service improvement, increasing availability of opioid analgetics, local anaesthetics and non-steroid anti-inflammatory drugs as well as education of the medical staff, patients and families.