Who Pain Ladder


Who Pain Ladder

What are the steps in the WHO pain ladder?

WHO Analgesic Ladder and Opioid Crisis – The World Health Organization (WHO) first released a document addressing cancer pain relief in 1986, which stipulated a Three-step analgesic ladder as the guideline for developing treatment plans for cancer pain.22 It was revised in 1996.23 Prior to the guideline’s release, many patients suffered from unnecessary pain due to the stigma and fear associated with both the prescription of opioids and their utilization.24 The WHO analgesic ladder specifies treatment on pain intensity, from simple analgesics for mild pain to opioid analgesics for moderate and severe pain. Its three steps are: Step 1 Non-opioid plus optional adjuvant analgesics for mild pain; Step 2 Weak opioid plus non-opioid and adjuvant analgesics for mild to moderate pain; Step 3 Strong opioid plus non-opioid and adjuvant analgesics for moderate to severe pain. It is advised to move up one step when there is persistent pain. In case of toxicity or severe adverse effects, providers are advised to either reduce medication doses or move down one step. The ladder provides five simple recommendations for the usage of analgesics: by mouth, by clock, by ladder, by individual and attention to the detail. Just two years following its release, it was already validated in 80–90% of cases.25 The stepwise approach had tremendous value when it was introduced for its conservative and simple principles for pain management, which could be applied everywhere in the world, even in those underdeveloped countries with fewer pain management specialists. It has been of significant benefit for the control of pain worldwide. Until now, this guideline has remained applicable, not only in cancer pain management but also for acute pain and chronic pain requiring analgesics.26 The three-step ladder for cancer pain has also been commonly employed in CNCP, which very likely contributed to opioid analgesic overuse and escalation.26, 27 For ensuring patients with safer and more effective chronic pain management, the CDC in 2016 released a guideline regarding the prescribing of opioid pain medication for adult patients with CNCP in the primary care setting. The concept of pain relief as a fundamental human right acknowledges access of patients to essential medicines, including opioid medications for the management of pain. According to the WHO analgesic ladder, the provider prescribes opioid analgesics to patients based on the patient’s report of how serious the pain is. In the United States, the top 4 opioids prescribers are physicians in family practice, internal medicine, and nurse practitioners, and physician’s assistants, with the majority of them not specifically trained in pain control to a significant degree.14, 28 – 30 It has been shown that chronic pain patients obtain opioid medication easily from physicians.2, 31 A study in 2014 reported that patients received opioid analgesic prescriptions from two providers in 34.6% of cases, 14.2% from three providers, and 11.9% from four or more prescribers.32 There were 240 million opioid prescriptions dispensed in 2015 in the United States, almost one for every adult in the general population.33 Prescriptions thus have probably been a major contribution to the issues of opioid addiction and overdose deaths.34 Furthermore, some physicians prescribe more than one-month of opioid medication to patients, 35 while too many patients leave hospitals with bottles of unnecessary opioid analgesics.2 There are many cases of nonmedical users of opioids obtaining them from their relatives or friends, just for experimentation or for “getting high”.36 United States poison control centers reported 188,468 prescription opioid exposures among children aged <20 years old from 2000 to 2015.37 More than 2,000,000 people are suffering from prescription opioid-related substance abuse currently, 38 which highlights the fact that this is a particularly devastating problem in public health. Therefore, how to prescribe the opioid analgesics appropriately can be particularly challenging and stressful for primary care providers. Changes in opioid prescription policies should include sufficient training, including the applicability of analgesic ladder, which is a valuable guideline addressing both cancer and non-cancer pain.

What is the meaning of pain ladder?

‘Pain ladder’, or analgesic ladder, was created by the World Health Organization (WHO) as a guideline for the use of drugs in the management of pain. Originally published in 1986 for the management of cancer pain, it is now widely used by medical professionals for the management of all types of pain.

Will I ever be pain free again?

Five things I wish I knew earlier in my journey with chronic pain I ‘ve been living with chronic pain for more than a decade. It began in 2009 with nerve damage after emergency groin surgery. Four years later, I fell and hit my head. That fall led to a constant headache, a whistling sound in my ear, back and hip pain, tingling and numbness in my hands and feet, electrical shocks in my legs, muscle soreness, and random pain and burning sensations throughout my body.

Years later, after numerous doctor visits and tests, I was diagnosed with fibromyalgia, tinnitus, neuropathy, chronic fatigue, and depression. I had a hard time adjusting to the pain. I let my symptoms control me. My quality of life suffered along with my physical conditioning. Here are five things I wish I had known earlier in this journey, much of which I learned while attending a three-week outpatient program at the in 2012 and again in 2018.

Each of these would have made my journey easier and might help others living with chronic pain. Pain isn’t just physical. Chronic pain clearly affects the body, but it also affects emotions, relationships, and the mind. It can cause anxiety and depression which, in turn, can make pain worse.

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At work, I couldn’t handle the stress. I had trouble concentrating, missed deadlines, and made mistakes. At home, I didn’t sleep well and was irritable. I was plagued by negative thoughts like, “Do I want to live like this the rest of my life?” When I reluctantly quit my job at the recommendation of my doctors, I lost more than a regular paycheck and valuable benefits like health insurance and retirement savings: I also lost a sense of self-purpose and self-worth.

As I came to understand the connection between pain and emotional issues, I included mental health care as part of my pain management program to help control my mood and manage stress. Pain isn’t always curable. Medical professionals don’t have all the answers, nor do they always have cures.

There is no magic pill or intervention that makes chronic pain disappear. Sadly, some people with chronic pain may never be pain free again. To try to relieve my pain, I’ve bounced between all types of health care providers: primary care physicians, pain specialists, rheumatologists, neurologists, audiologists, physical therapists, surgeons, and psychiatrists.

I’ve been through X-rays, ultrasounds, MRIs, CT scans, and all sorts of other diagnostic tests. I’ve taken opioid painkillers, non-opioid painkillers, vitamins, and herbs; attended professional lectures; spent countless hours searching the internet; and even had surgery.

  • Some of these helped relieve my pain, some didn’t, and some even made things worse.
  • Meanwhile, they all cost me time and money and delayed my pain rehabilitation.
  • Not all pain means harm.
  • We learn at an early age that touching something hot hurts.
  • But the presence of pain doesn’t always mean danger.
  • There are two types of pain: acute and chronic.

Acute pain is the body’s normal response to tissue damage or injury and needs immediate medical treatment. It heals and generally lasts less than three months. Chronic pain is an abnormal response and doesn’t improve with time. It can occur in the absence of tissue damage and persist long after the body heals.

It changes how nerves and the brain process pain, as misfiring nerve signals continue to tell the body it hurts. By being able to tell the difference between new acute pain and chronic pain, I have changed how I react to chronic pain by not being so guarded or worried about it. Thoughts, feelings, and behaviors are connected.

Chronic pain makes it easy to feel distressed, to give up and become a victim. “Woe is me,” “life isn’t fair,” and other unhelpful thoughts increase one’s focus on pain and can make it worse. It fosters anger, frustration, and hopelessness. And it leads to what experts’ call pain catastrophizing — an exaggerated negative response toward actual or anticipated pain.

I did my share of catastrophizing. When my symptoms first started, all I could think about was how much I hurt and if the suffering would ever end. I even journaled symptoms and rated my pain each day so I could share with my doctors what I was experiencing. I became overwhelmed. Move on. If chronic pain doesn’t mean more harm and there aren’t any magical medical answers, what’s left to do? Accept the pain as the “new normal,” adapt to it, and learn how to manage it.

Of course, that’s easier said than done. Here are I have found helpful to calm the body and mind and make it easier to function include:

Reduce pain behaviors. The body’s natural physical, vocal, and verbal reactions to pain, such as rubbing, wincing, groaning, limiting activity, and complaining, fuel anxiety and intensify pain. I try to avoid these behaviors so as not to draw attention to my pain. It’s harder to hurt when you don’t think about it. I often use watching a funny movie, listening to music, talking to a friend, or doing some other social activity to focus on something other than the pain. Exercise. While it may seem counterintuitive, movement helps reduce pain and improves conditioning. I try to walk each day even though my body hurts. Limit when needed. People with chronic pain often do too much when they are having good days and not enough when they are having bad days. I have learned limits and try to pace myself so I don’t worsen my symptoms. Lighten your load. Why make things harder than what they are? Techniques like good body mechanics make activities easier, not harder. Heavy lifting, for example, makes my pain worse. So instead of carrying a heavy load in one trip, I divide it into lighter loads and make multiple trips. Relax and ease tension. Pain and tension can form a viscous circle. Muscles tighten and put pressure on nerves resulting in even more pain. I do deep breathing and muscle relaxation exercises to help reduce tension.

Is tramadol a strong or weak opioid?

Tramadol is considered as either a weak opioid or a strong opioid, depending on the administered dose.9 The term weak opioid should not encourage lack of caution in prescribing. The term ‘opioid’ refers to all compounds that bind to opioid receptors.

What are the 4 A’s of pain?

MONITORING – On the basis of risk assessment, patients can be stratified by their level of risk, and therapy can be structured appropriately to minimize risk and guide monitoring.6, 13 Patients at minimal risk can receive minimal structure, whereas those at greater risk can receive more structure, such as more frequent visits, fewer pills per prescription, specialist-level care (eg, an addiction specialist or psychotherapist), and UDTs.

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An opioid treatment agreement, discussed and signed by the patient before opioid therapy begins, outlines the risks and benefits, explains what is expected of the patient, educates the patient about drug storage, and helps the patient distinguish between acceptable and unacceptable drug-taking behaviors.16, 30 Refusal to sign such an agreement may indicate misuse or abuse issues but may arise from concerns or psychological issues unrelated to substance abuse or misuse.

Patients must be made aware of the responsibility of safeguarding these medications against diversion by friends, family, or visitors who may have access to medications left out or in unlocked locations. Multiple studies have shown that 50% or more of prescription opioids diverted for nonmedical use are obtained from friends and family.31, 32 The physician can benefit from consulting endorsed guidelines for using opioids to treat chronic pain, available from various state medical boards and the Federation of State Medical Boards.7, 30 A recent survey showed that these techniques led to resolution of aberrant behaviors in more than 40% of problematic patients when administered by a multidisciplinary team comanaged by a pharmacist and a nurse practitioner.33 As comanagers, pharmacists and nurse practitioners can play a critical role by directly educating and monitoring patient compliance with opioid-based treatment regimens.

  1. When using opioids to treat chronic pain, physicians should be observant of aberrant drug-taking behavior, which can prompt them to suspect deeper problems with abuse or diversion of opioids.
  2. Ongoing assessment of the 4 A’s of pain treatment is helpful.
  3. The 4 A’s—analgesia, activities of daily living, adverse events, and aberrant drug-taking behaviors—can structure assessment and serve as a means by which to record patient response to therapy.

The Pain Assessment and Documentation Tool is useful for evaluating outcomes in those 4 domains.34 Documentation of all aspects of patient care, from the initial examination to later visits, reduces the risk of regulatory sanction and is an important part of risk management.6, 35 However, not all instances of aberrant drug-taking behavior are related to abuse or addiction on the part of the patient.

  • For example, a patient taking more medication than indicated may be doing so to obtain adequate analgesia, indicating that he or she has become tolerant to the medication ( Table 4 ).
  • Diversion of prescription opioids may be unintentional on the part of the patient, such as a case in which an adolescent who uses drugs recreationally takes prescription opioids from a parent or grandparent’s medicine cabinet ( Table 4 ).

Certainly, frank abuse and criminal diversion of opioid medications may also occur.

What is stronger than tramadol?

Can I use tramadol or oxycodone with alcohol? – You should avoid taking tramadol or oxycodone with alcohol. Both tramadol and oxycodone carry an FDA Black Box Warning about taking them with other central nervous system depressants, including alcohol. It increases your risk of a potentially fatal overdose.

What are the 5 parts of pain?

Nociceptive pain occurs in 5 phases: 1) Transduction, 2) Conduction, 3) Transmission, 4) Modulation, 5) Perception.

Why no ibuprofen after surgery?

Patients are often instructed not to take ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) before or after surgery because of increased bleeding risk. But available evidence suggests that ibuprofen does not increase the risk of bleeding after plastic surgery procedures, according to a research review in the April issue of Plastic and Reconstructive Surgery ®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

How rare is it to not feel pain?

Introduction – Pain alters the quality of life more than any other health-related problem, and it is one of the implements of body protection. It interferes with sleep, mobility, nutrition, thought, sexual activity, emotional well-being, creativity, and self-actualization.

  • Congenital insensitivity to pain is a rare disorder, first described in 1932 by Dearborn as Congenital pure analgesia.
  • Congenital insensitivity to pain and anhydrosis (CIPA) is a very rare and extremely dangerous condition.
  • People with CIPA cannot feel pain,
  • Pain-sensing nerves in these patients are not properly connected in parts of brain that receive the pain messages.

CIPA is extremely dangerous, and in most cases the patient doesn’t live over age of 25. Although some of them can live a fairly normal life, they must constantly check for cuts, bruises, self-mutilations, and other possible unfelt injuries. Self-mutilation is an almost invariable feature of this disorder, most often involving the teeth, lips, tongue, ears, eyes, nose, and fingers.

Can humans ignore pain?

Pain is a warning system for the body – Updated 12/5/2022 Pain is something that everyone has experienced at some point in their lifetime; whether it is emotional or physical pain. So, we can all agree that pain is a normal life experience, If you are not able to experience pain it is a medical condition called congenital analgesia.

People with this condition often end up with many physical injuries (burns, fractures, infections) due to the lack of a warning system, which is what pain is. Pain is a way for the body to protect itself and is a danger signal to the brain. If you touch a hot oven or hot pan with your hand a danger signal (nerve impulse) will be sent from your hand to your brain saying; Look over here, we have a situation.

The brain decides to either acknowledge the danger signal from the hand or ignore it. Our brain likes to protect our body, so we pull our hand off the hot oven. One cool thing about our brain is it does have the ability to ignore pain if there is a greater risk.

  1. For example, if you step off a curb and twist your ankle; what do you do? You may fall to the ground and grab your ankle because it hurts and after some time limp to your car.
  2. But what happens if a bus is coming down the street when you fall and twist your ankle? Suddenly your sprained ankle is as big of an issue as the bus coming down the street! Our brain can ignore the pain from the sprained ankle in order to get out the way of the bus.
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Now once you are safe and the adrenaline has decreased your ankle will begin to hurt and this is normal. Pain is an indication that your body has started the healing process for your ankle and you didn’t even have to tell your body to do this! Our bodies just do this on their own! When we experience pain or the brain creates a little pain memory; what happened, who was with you, smells, among many other things go into creating this memory.

  1. There are many parts of the brain that are involved in making memories and this is the case with injuries and pain as well.
  2. Often once the injury heals the pain memory is harder to recall and is sometimes forgotten.
  3. But sometimes the pain doesn’t go away, and more and more areas of the brain get pulled into the pain memory and start paying attention to the area of the body that is painful.

When this happens, it may become harder to concentrate, move, sleep and perform activities you had previously performed without really thinking about it. This is where physical therapy can be beneficial. Research has shown that physical therapy can be beneficial to people who are experiencing chronic pain.

  1. There are many interventions we can provide to help you improve your level of function.
  2. We have hands-on techniques which can improve how joints and muscles are moving.
  3. Along with this we provide education on pain; it has been shown in research that educating patients about pain, the nervous system, and the brain can help calm the nervous system and reduce pain levels.

We can help re-educate the brain that moving the body part in pain isn’t going to cause injury. Last, but not least, is exercise. The effect exercise can have on both our minds and bodies is amazing and too long to list in this post. Our bodies are meant to move, and movement helps calm the brain and nerves.

Is pain a reputable journal?

How many people read PAIN ? – A subscription to PAIN is one benefit of membership in IASP, which means more than 7,000 individuals have access to the journal. In addition to those who access the journal electronically, approximately 3,500 paper issues of PAIN are mailed monthly.

  1. What is the current Impact Factor of PAIN ? Our official journal Impact Factor now stands at 7.926.
  2. The Impact Factor measures, among other criteria, how often our journal articles are cited during a given time period.
  3. PAIN is among the premier pain journals, and is also highly ranked in other journal categories.

PAIN considers the following types of manuscripts:

  • Clinical/Basic Science Research Reports
  • Clinical Notes (brief reports on clinical cases)
  • Comprehensive Reviews
  • Topical Reviews (invited only)
  • Commentaries (invited only)
  • Letters to the Editor

For further information, see the,

Is The Journal of Pain peer-reviewed?

The Journal of Pain

Discipline Anesthesiology
Language English
Edited by Tonya M. Palermo
Publication details
Former name(s) APS Journal, Pain Forum
History 1992-present
Publisher Elsevier on behalf of the United States Association for the Study of Pain
Frequency Monthly
Impact factor 4.621 (2019)
Standard abbreviations
ISO 4 J. Pain
ISSN 1526-5900
LCCN sn99009246
OCLC no. 612294357
  • Journal homepage
  • Online access
  • Pain Forum online archive
  • APS Journal online archive

The Journal of Pain is a monthly peer-reviewed medical journal published by Elsevier on behalf of the United States Association for the Study of Pain and covers research and reviews on pain, including anesthesiology and palliative care and related educational and policy issues.

  • The editor-in-chief is Tonya M.
  • Palermo ( University of Washington ).
  • The journal was established in 1992 as the APS Journal and was renamed Pain Forum in 1995 before obtaining its current name in 2000, with volume numbering restarting at 1.
  • In December 2019, following the bankruptcy of the American Pain Society, the newly formed United States Association for the Study of Pain purchased the journal.

According to the Journal Citation Reports, the journal has a 2019 impact factor of 4.621. The Journal is included in the Index Medicus and in MEDLINE,

Is Pain Research and Management peer-reviewed?

prm – About this journal / About this Journal Pain Research and Management is a peer-reviewed, open access journal which publishes original research articles and review articles involving laboratory, including neuroimaging and neurophysiology, and clinical findings in the field of pain research.

Chronic Pain Neuropathic Pain Headache Anaesthesia Dentistry Oral Medicine Rheumatology Drug Development

ISSN: 1203-6765 (Print) ISSN: 1918-1523 (Online) DOI: 10.1155/7040

Pain Research and Management is an open access journal. All articles are immediately available to read and reuse upon publication. More information about our Open Access policy can be found on our, Article of the Year Award: Outstanding research contributions of 2021, as selected by our Chief Editors., : prm – About this journal

Is the clinical journal of pain peer-reviewed?

Explores all aspects of pain and its effective treatment, bringing readers the insights of leading anesthesiologists, surgeons, internists, neurologists, orthopedists, psychiatrists and psychologists, clinical pharmacologists, and rehabilitation medicine specialists.

This peer-reviewed journal presents timely and thought-provoking articles on clinical dilemmas in pain management; valuable diagnostic procedures; promising new pharmacological, surgical, and other therapeutic modalities; psychosocial dimensions of pain; and ethical issues of concern to all medical professionals.


The journal also publishes Special Topic issues on subjects of particular relevance to the practice of pain medicine. Front File – 2015 to Present Archives available for purchase