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Is the WHO pain ladder still used?

Clinical Significance – Even with the drawbacks, the strategy includes a simple and effective guideline on administering analgesics that is valid even today. The main components include:

Oral dosing of drugs whenever possible (as opposed to intravenous, rectal, etc.). Around-the-clock rather than on-demand administration. The prescription must follow the pharmacokinetic characteristics of the drugs. Analgesics must be prescribed according to pain intensity as evaluated by a pain severity scale. For this purpose, a clinical examination must combine with an adequate pain assessment. Individualized therapy (including dosing) addresses the concerns of the patient. This method presupposes that there is no standardized dosage in pain treatment. This is probably the biggest challenge in pain medicine, as the dosology must be continuously adapted to the patient, balancing desired effects and possible side effects. Proper medication adherence, as any dosing alterations can lead to pain recurrence.

Pain accounts for one of the top five reasons for consultation. A better understanding of the physiology and psychological aspects of pain is necessary to take an ideal approach to pain control. The WHO analgesic ladder can remain a foundational treatment for chronic pain, upon which clinicians can add new modalities.

The WHO analgesic ladder has become a standard of care for cancer patients worldwide due to its effectiveness in relieving cancer pain without causing significant side effects. Studies have shown that following the WHO analgesic ladder can improve patient outcomes, reduce hospital stays, and improve quality of life.

Additionally, using the ladder can help reduce opioid misuse and abuse by ensuring that opioids are only used when necessary, The WHO analgesic ladder also guides titrating medications according to the needs of the patient. This allows clinicians to adjust doses to provide optimal relief from cancer pain while avoiding unwanted side effects.

1. Additionally, it encourages clinicians to assess the response to treatment regularly to ensure that their treatment plan remains adequate.
2. Overall, the WHO analgesic ladder has become an essential tool for managing cancer pain due to its ability to provide adequate relief while minimizing risks associated with opioid use.

Therefore, it is an important part of any comprehensive cancer care plan and should be used whenever possible to ensure optimal outcomes for patients suffering from cancer pain.

Who created the three step analgesic 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.

When was the WHO pain ladder invented?

• Journal List
• Can Fam Physician
• v.56(6); 2010 Jun
• PMC2902929

As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more about our disclaimer. Can Fam Physician.2010 Jun; 56(6): 514–517.

• Twenty-four years of experience Pain remains one of the main reasons for medical consultation worldwide.
• Numerous organizations and scientific associations have made efforts to find solutions for this problem and to facilitate the treatment of pain.
• In 1986 the World Health Organization (WHO) presented the analgesic ladder as a framework that physicians could use when developing treatment plans for cancer pain.

This therapeutic guideline paved the way for considerable improvements in the management of cancer pain, but is it still a valid tool 24 years later? The WHO proposed the analgesic ladder following the recommendations of an international group of experts.

The document was translated into 22 different languages and has served as a catalyst for increasing awareness around the world of the importance of treating pain in cancer patients.1 – 6 The analgesic ladder proposed the use of a limited number of relatively inexpensive medications, such as morphine, in a stepwise approach.

It helped legitimize the use of opioids for treatment of cancer pain and encouraged numerous worldwide teaching campaigns on the use, benefits, and side effects of narcotics in the treatment of pain. Both the 1986 and 1997 1, 2 WHO treatment guides for cancer pain provide explanations of the pathophysiology of such pain, how to make adequate assessments, how to choose analgesics, and how to use the ladder.

What is the golden treatment in analgesic of severe pain?

Acute Postoperative Pain Management in the Older Patient Opioids remain the gold standard for the treatment of moderate to severe acute pain. Morphine is a potent opiate analgesic that can be administered orally, intramuscularly, subcutaneously and intravenously.

Morphine is easily titrated, provides a lasting analgesic effect and is inexpensive. Intravenous morphine can be safely used in cognitively intact older patients. Acutely, after surgery, the total dose of morphine, pain relief achieved and risk of adverse events is not significantly different than in younger patients.

Postoperatively, following transfer from the postanesthesia care unit, decreases in opioid requirements associated with advancing age have been demonstrated, whether received through intravenous patient-controlled analgesia (IVPCA) or by nursing administration.

It has also been demonstrated that cognitively intact older patients are quite capable of using an IVPCA, achieve similar reductions in pain and self-administer less overall opioid; however, they use the IVPCA for a longer duration compared with younger adults. A Cochrane review concluded that IVPCA provided superior analgesia and improved patient satisfaction compared with other conventional methods of delivery.

Morphine is broken down in the liver to pharmacologically active metabolites (morphine-6-glucuronide and morphine-3-glucuronide), which are then excreted by the kidneys. In the setting of renal impairment, these metabolites can accumulate, causing respiratory depression and/or neuroexcitation.

In the setting of renal impairment, opioids that do not have active metabolites, such as fentanyl, are preferred for IVPCA. One potential problem with IVPCA is the practice of patient-controlled analgesia (PCA) by proxy (the administration of an IVPCA bolus dose by someone other than the patient). PCA by proxy has been associated with several fatalities in adult patients.

This prompted a review by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which recommended that no patient visitors be allowed access to the PCA device. The JCAHO also recommended PCA by nurse proxy be utilized only at those institutions where patient selection criteria and monitoring standards have been established.

PCA by proxy is of particular concern in older patients who are not cognitively intact and cannot reliably use PCA. Oral opioids are, of course, also widely used for acute pain management. Oral oxycodone undergoes less first-pass metabolism and has higher bioavailability than oral morphine. This results in more consistent plasma levels postadministration.

Unlike morphine, renal impairment does not appear to affect plasma concentrations of oxycodone or its active metabolite oxymorphone. This is an important factor to consider, as renal impairment is a common comorbidity in the older population. The administration of scheduled controlled-release oxycodone may avoid the peaks and troughs associated with intravenous bolus dosing, resulting in stable plasma levels and improved pain control.

A combination of long- and short-acting oxycodone was equally effective as IVPCA in patients undergoing total hip and total knee arthroplasty. Although the incidence of side effects was equal between groups, opioid consumption in the oxycodone group was significantly less than in the IVPCA group. Rothwell et al.

showed oral oxycodone provided equivalent analgesia to IVPCA in a group of patients, aged 60–79 years, post-total hip arthroplasty. There is emerging evidence that oral oxycodone may be more cost effective than IVPCA in patients who have had laparoscopy surgery.

• Scheduled oral oxycodone (controlled release) improved patients’ pain control, patient satisfaction, and decreased postoperative nausea and vomiting compared with intravenous morphine PCA in a group of patients post-lumbar discectomy.
• Oral oxycodone is also being administered with increased frequency as part of a multimodal approach to acute postoperative pain.

Oral and IVPCA approaches are just two of many ways to administer opioids. A discussion of the many differences in approach is, unfortunately, beyond the scope of this article. Common opioid side effects reported in the literature include urinary retention, pruritus, nausea and vomiting, CNS effects and respiratory effects.

The incidence of each adverse drug effect varies by the specific opioid given and the route of administration. By far the most feared opioid-induced toxicity is respiratory depression. Respiratory depressive side effects comprise the majority of severe opioid adverse effects. Adverse outcomes from respiratory depression can typically be prevented through opioid titration and vigilant monitoring.

When necessary, naloxone (an opioid antagonist) can be administered. Naloxone can cause opioid withdrawal, sudden severe pain, hypertension and pulmonary edema. The manufacturer of naloxone recommends administering this medication in the lowest effective dose to geriatric patients as it has not been thoroughly studied in this population, although clinical experience suggests there is no difference between older and younger patients.

1. Opioid tolerance is an increasingly prevalent challenge in perioperative care.
2. Approximately 15 years ago, the concept of ‘pain as the fifth vital sign’ was popularized in the USA, and aggressive pain treatment was mandated by hospital credentialing organizations such as JCAHO.
3. Unfortunately, this involved the use of high doses of opioids for chronic (and often ill-defined) conditions, despite minimal evidence that opioids are effective as long-term analgesics.

With chronic use of opioids, opioid receptors decrease in population, as well as possibly in excitability. This ‘downregulation’ of opioid receptors manifests as increasing doses of opioids needed to obtain the same effect, and is usually clinically noted as ‘tolerance’ to a drug.

Unfortunately, in up to 30–40% of patients that chronically consume opioids, opioid-induced hyperalgesia occurs. This condition refers to a generalized and increasing pain sensitivity that occurs with chronic opioid use. Patients note that many areas of their body hurt, rather than just the region that they originally sought treatment for.

Minor medical procedures, such as immunizations, venopunctures or intravenous catheter insertions, are perceived as excruciating. Higher doses of opioids are often prescribed by well-intentioned clinicians, but are not helpful, and frequently cause a further pain sensitivity.

What is the most effective pharmacological method of pain control?

Administration – Nonopioid analgesic agents

Acetaminophen (paracetamol) : The recommended dose for adults is 650 mg to 1000 mg every 4 to 6 hours, a maximum of 4 grams/day. In children, the recommended dose is 15 mg/kg every 6 hours, up to 60 mg/kg/day. Acetaminophen is available to be administered orally (tablet, capsule, syrup, oral solution, or suspension), rectally (rectal suppository), or intravenously. Nonsteroidal anti-inflammatory drugs (NSAIDs) : Currently, more than 20 different NSAIDs are commercially available. The choice of the agent depends upon several factors (eg., comorbidities, risk of bleeding). Also, the response to different NSAIDs vary between patients, and the mechanisms for these distinct responses are only partially understood. Thus, doses depend on the specific drug, and the recommendation is to prescribe the lowest effective dose for each patient for the shortest period. Listed below are various commonly known NSAIDs with their respective doses for analgesia and anti-inflammation:

Aspirin (acetylsalicylic acid) : Is dosed 325 to 650 mg every 4 to 6 hours. The maximum dose is 4000 mg/day. Aspirin is available for oral (caplet, capsule, tablet) or rectal (suppository) administration. Diclofenac : 50 mg every 8 hours. The maximum daily dose is 150 mg. Diclofenac is available for oral (tablet, capsule, packet), intravenous, topical (cream, gel, patch, solution), or ophthalmic administration. Ibuprofen : It is dosed 400 mg every 4 to 6 hours. The maximum daily dose is 3200 mg (acute) or 2400 mg (chronic). Ibuprofen is available for oral (capsule, tablet, suspension) or intravenous administration. Indomethacin : Immediate release: 25 to 50 mg every 8 to 12 hours. Controlled release: 75 mg once or twice daily. The maximum dose is 150 mg/day. Indomethacin is available for oral (capsule, suspension), intravenous, or rectal (suppository) administration. Meloxicam : Dosing is 7.5 to 15 mg once daily. The maximum daily dose is 15 mg. Meloxicam is available for oral (tablet, capsule, suspension) or intravenous administration. Naproxen : 250 to 500 mg every 12 hours (naproxen base) or 275 to 550 mg every 12 hours (naproxen sodium). The maximum daily dose is 1250 mg acute or 1000 mg chronic for naproxen base and 1375 mg acute or 1100 mg chronic for naproxen sodium. Naproxen is available for oral (capsule, suspension, tablet) administration only. Celecoxib : 200 mg daily or 100 mg every 12 hours. The maximum dose is 400 mg/day. Celecoxib is available for oral (capsule) administration only.

Antidepressant medications : Among the tricyclic antidepressants and selective serotonin and norepinephrine reuptake inhibitors, amitriptyline and duloxetine have the best-documented analgesic effects, respectively.

Amitriptyline : Dosing is 25 to 150 mg orally (tablet) once daily or in two divided doses. The maximum single and daily doses are 75 mg and 150 mg, respectively. Caution must be taken in patients 65 years old or older with maximum daily doses above 75 mg. Duloxetine : Dosing is 60 to 120 mg orally (capsule) once daily or in two divided doses. The maximum daily dose is 120 mg.

Antiepileptic medications :

Gabapentin : 300 to 600 mg orally (capsule, tablets, solution) three times per day with a maximum daily dose of 1800 mg for postherpetic neuralgia or 300 to 1200 mg orally three times per day with a maximum daily dose of 3600 mg. Pregabalin : 300 to 600 mg/day orally in two divided doses.

Local anesthetics :

Lidocaine : As a patch, lidocaine is available at a concentration of 1.8% or 5%. The recommendation is to apply 1-3 patches to intact skin for up to 12 hours/day. Other commercially available presentations include topical solutions, creams, gels, ointment, and lotions.

Opioid agents Opioids are available in diverse dosage forms to use for several routes of administration: oral, transdermal, intramuscular, intravenous, subcutaneous infusion, rectal, epidural, intrathecal, intranasal, and transmucosal. The rationale for each route of administration, dosage range, and dosage form is dependent on a number of factors.

What is the pain ladder scale UK?

0 = no pain 1 = mild pain 2 = moderate pain 3 = severe pain. This pain score corresponds to the three steps in the WHO analgesic ladder.

When was the WHO pain ladder invented?

• Journal List
• Can Fam Physician
• v.56(6); 2010 Jun
• PMC2902929

As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more about our disclaimer. Can Fam Physician.2010 Jun; 56(6): 514–517.

Twenty-four years of experience Pain remains one of the main reasons for medical consultation worldwide. Numerous organizations and scientific associations have made efforts to find solutions for this problem and to facilitate the treatment of pain. In 1986 the World Health Organization (WHO) presented the analgesic ladder as a framework that physicians could use when developing treatment plans for cancer pain.

This therapeutic guideline paved the way for considerable improvements in the management of cancer pain, but is it still a valid tool 24 years later? The WHO proposed the analgesic ladder following the recommendations of an international group of experts.

The document was translated into 22 different languages and has served as a catalyst for increasing awareness around the world of the importance of treating pain in cancer patients.1 – 6 The analgesic ladder proposed the use of a limited number of relatively inexpensive medications, such as morphine, in a stepwise approach.

It helped legitimize the use of opioids for treatment of cancer pain and encouraged numerous worldwide teaching campaigns on the use, benefits, and side effects of narcotics in the treatment of pain. Both the 1986 and 1997 1, 2 WHO treatment guides for cancer pain provide explanations of the pathophysiology of such pain, how to make adequate assessments, how to choose analgesics, and how to use the ladder.