Pain ladder
"Pain ladder",oranalgesic ladder,was created by theWorld Health Organization(WHO) as a guideline for the use of drugs in the management of pain. Originally published in 1986 for the management ofcancer pain,it is now widely used by medical professionals for the management of all types ofpain.
The general principle is to start with first step drugs, and then to climb the ladder if pain is still present. The medications range from common,over-the-counter drugsat the lowest rung, to strongopioids.
The ladder
[edit]The WHO guidelines recommend prompt oral administration of drugs ( "by the mouth" ) when pain occurs, starting, if the patient is not in severe pain, with non-opioid drugs such asparacetamol(acetaminophen) or aspirin,[1]with or without "adjuvants" such asnon-steroidal anti-inflammatory drugs(NSAIDs) includingCOX-2 inhibitors.Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, a weak opioid such ascodeine,dihydrocodeineortramadolis added to the existing non-opioid regime. If this is or becomes insufficient, a weak opioid is replaced by a strong opioid, such asmorphine,diamorphine,fentanyl,buprenorphine,oxymorphone,oxycodone,orhydromorphone,while continuing the non-opioid therapy, escalating opioid dose until the patient is pain free or at the maximum possible relief without intolerable side effects. If the initial presentation is severe pain, this stepping process should be skipped and a strong opioid should be started immediately in combination with a non-opioidanalgesic.[2]
The guideline directs that medications should be given at regular intervals ( "by the clock" ) so that continuous pain relief occurs, and ( "by the individual" ) dosing by actual relief of pain rather than fixed dosing guidelines. It recognizes that breakthrough pain may occur and directs immediate rescue doses be provided.
Step 1. | Mild pain: | Non-opioid | + | Optional adjuvant | If pain persists or increases, go to step 2. | ||
---|---|---|---|---|---|---|---|
Step 2. | Moderate pain: | Weak opioid | + | Non-opioid | + | Optional adjuvant | If pain persists or increases, go to step 3. |
Step 3. | Severe pain: | Strong opioid | + | Non-opioid | + | Optional adjuvant | Freedom from pain. |
The usefulness of the second step (weak opioid) is being debated in the clinical and research communities. Some authors challenge the pharmacological validity of the step and, pointing to their higher toxicity and low efficacy, argue that a weak opioid, with the possible exception oftramadoldue to its unique additional actions (seetramadol § Pharmacology), could be replaced by smaller doses of a strong opioid.[2]
Not all pain yields completely to classic analgesics, and drugs that are not traditionally considered analgesics, but which reduce pain in some cases, such assteroidsorbisphosphonates,may be employed concurrently with analgesics at any stage.Tricyclic antidepressants,class Iantiarrhythmics,oranticonvulsantsare the drugs of choice forneuropathic pain.Up to 90 percent of cancer patients, immediately preceding death, use suchadjuvants.Many adjuvants carry a significant risk of serious complications.[2]
History
[edit]The ladder was developed by a team that includedJan StjernswärdandMark Swerdlow.[3]
See also
[edit]- Opioid comparison,an example of anequianalgesicchart
- Pain management
References
[edit]- ^WHO 2017.
- ^abcSchug & Auret 2008.
- ^Reynolds, L.A.; Tansey, E.M., eds. (2004).Innovation in pain management: the transcript of a Witness seminar held by the Wellcome Trust Centre for the History of Medicine at UCL, London, on 12 December 2002.Wellcome Trust Centre for the History of Medicine at University College London.ISBN978-0-85484-097-7.
Bibliography
[edit]- Schug, Stephan A; Auret, Kirsten (26 September 2008).Clinical pharmacology: principles of analgesic drug management.CRC Press. pp. 103–122.ISBN9780340940075.,inSykes et al (2008)
- Sykes, Nigel; Bennet, Michael; Yuan, Chun-su, eds. (2008).Clinical Pain Management: Cancer Pain.CRC Press.ISBN978-0-340-94007-5.
- Cancer-Related Pain Management.Cancer Care Ontario.2012.
The pain ladder has appeared in several publications.
The original 1986 presentation of the pain ladder is on page 51 of this booklet.
- World Health Organization (1986).Cancer pain relief(PDF)(1 ed.). Geneva: World Health Organization.ISBN9241561009.
Later presentations are in updated publications.
- World Health Organization (1996).Cancer pain relief. With a guide to opioid availability(2 ed.). Geneva: WHO.ISBN92-4-154482-1.
- World Health Organization (1998).Cancer pain relief and palliative care in children.Geneva: WHO.ISBN978-92-4-154512-9.
- "WHO's cancer pain ladder for adults".Cancer.WHO. 2017. Archived fromthe originalon August 7, 2003.Retrieved21 May2017.