Presented in 1986, the World Health Organization (WHO) analgesic ladder provided a framework for the stepwise medical management of cancer-related pain. 1 This 3-step ladder begins with nonopioid analgesics with or without nonpharmacological approaches for mild pain, continues with weak opioid medications (eg, codeine) with or without nonopioid analgesics and adjuvants for mild-to-moderate pain, and progresses to strong opioids (eg, oxycodone) with or without nonopioid analgesics and adjuvants for moderate-to-severe pain. 1 The American Pain Society’s identification of pain as the “fifth vital sign” in 1995 portended the increased importance of not only adequate treatment of pain in patients but also education of health care professionals. 2, 3 Eventually, a modified version of the 3-step ladder placed interventional pain management as a fourth step. 4, 5 Development of this algorithmic approach aimed to control refractory or intractable pain in both an efficient and a safe manner, providing a rational and balanced method to maximize pain relief while minimizing side effects and risks.
Should the who analgesic ladder be stepwise?
However, with concerns growing regarding opioid use, a shift in the stepwise approach of the WHO analgesic ladder in an age of developing technology and surgical offerings could have profound implications for patients and public health. Surgical interventions potentially provide a long-term, cost-effective management strategy to reduce opioid use.
Is the three-step analgesic ladder appropriate for pain management in ESRD?
Pain is the one of the most common symptoms experienced by patients with ESRD; it impairs their quality of life and is undertreated. Most pain clinicians believe that the pain management approach of the World Health Organization (WHO) three-step analgesic ladder is applicable to the treatment of pat …
What is the first step in the pain ladder?
The original ladder mainly consisted of three steps[4]: First step. Mild pain: non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen with or without adjuvants Second step. Moderate pain: weak opioids (hydrocodone, codeine, tramadol) with or without non-opioid analgesics, and with or without adjuvants
What are the three principles of the analgesic ladder?
World Health Organization (WHO) Analgesic Ladder The three main principles of the WHO analgesic ladder are: “By the clock, by the mouth, by the ladder”. By the clock: To maintain freedom from pain, drugs should be given “by the clock” or “around the clock” rather than only “on demand” (i.e. PRN).
WHO analgesic ladder explained?
The 1986 version of the WHO analgesic ladder proposes that treatment of pain should begin with a nonopioid medication (Figure 1). If the pain is not properly controlled, one should then introduce a weak opioid. If the use of this medication is insufficient to treat the pain, one can begin a more powerful opioid.
What is the 2 step method to pain management?
Patients generally start on Step 1 of the ladder (paracetamol). As pain increases or is not well controlled on this, they progress to Step 2 which involves a stronger pain killer (weak opioid such as codeine).
Which treatment would be found on the first rung of the WHO analgesic ladder?
The WHO pain ladder (Figure 1) describes pain in terms of intensity and recommends that analgesics be prescribed starting at Step 1 (nonopioid analgesics, such as acetaminophen or non-steroidal anti-inflammatory drugs [NSAIDs]).
WHO pain relief ladder a second step treatment for moderate pain is?
Second step. Moderate pain: weak opioids (hydrocodone, codeine, tramadol) with or without non-opioid analgesics, and with or without adjuvants. Third step.
What is the WHO 3 step analgesic ladder?
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.
What are the 3 types of analgesics?
There are three broad categories of analgesic medications: (1) nonopioid analgesics, which includes the nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, dipyrone, and others; (2) a diverse group of drugs known as the "adjuvant analgesics," which are defined as "drugs that have primary indications other ...
Which of the following would be an example of the progression of medication in ascending order according the World Health Organization WHO analgesic ladder?
By the ladder: If pain occurs there should be prompt administration of drugs in the following order: • non-opiods (e. g. acetaminophen) • as necessary, mild opiods (e. g. codeine) • then strong opiods (e. g. morphine or hydromorphone) until the patient is free of pain.
Which drug is analgesic?
Analgesics are a class of medications designed specifically to relieve pain. They include acetaminophen (Tylenol), which is available over the counter (OTC) or by prescription when combined with another drug, and opioids (narcotics), which are only available by prescription.
What is the preferred treatment plan for chronic pain?
1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.
What does multimodal analgesia mean?
Multimodal analgesia consists of the administration of 2 or more drugs that act by different mechanisms for providing analgesia. These drugs may be administered via the same route or by different routes.
What is an example of adjuvant analgesic?
Commonly used drugs in this class include: baclofen (Lioresal), carisoprodol (Soma), cyclobenzaprine (Flexeril), diazepam (Valium), methocarbamol (Robaxin), orphenadine (Norflex), metaxalone (Skelaxin), and tizanidine (Zanaflex).
What are the different types of pain scales?
Pain Assessment ScalesNumerical Rating Scale (NRS)Visual Analog Scale (VAS)Defense and Veterans Pain Rating Scale (DVPRS)Adult Non-Verbal Pain Scale (NVPS)Pain Assessment in Advanced Dementia Scale (PAINAD)Behavioral Pain Scale (BPS)Critical-Care Observation Tool (CPOT)
Why add a fourth step to the pain ladder?
Retaining the use of pain intensity as the differentiator between steps, a fourth step could be added to the original pain ladder to accommodate very severe pain, such as occurs in the palliative setting in certain patients with advanced, particularly egregious forms of cancer. Pain specialists treat “very severe” noncancer pain as well. Severe to very severe pain may not respond to conventional pharmacologic treatment and may require intervention. This proposed change reflects modern clinical practice and our growing understanding of pain syndromes (Figure 3).
What are the steps of the Pain Ladder?
Its simple, progressive steps of 1) anti-inflammatory agents, 2) weak opioids, and 3) strong opioids is still fundamentally sound. In this article, Pergolizzi and Raffa present a thoughtful and detailed set of recommendations to modify the 3-step process. No doubt all of us have some thoughts about modifying the “WHO Pain Ladder,” based on the many new physical, interventional, and pharmacologic measures that have come forward since 1986. My message is that too many purveyors of potent opioid pharmaceuticals and invasive interventions have promoted and championed the use of these therapies, which have well-known complications, without first attempting regimens that are less onerous. Practical Pain Management desires that all pain practitioners make 2014 a year in which they develop and practice a “WHO Pain Ladder” protocol that is modified with some new measures to give our patients their best chance at a wide range of safe alternatives before resorting to potent opioids and invasive interventions.
What is the first step in pain management?
Step 1: Nonopioid Analgesics. Nonopioid analgesics include acetylsalicylic acid, acetaminophen, and selective and non-selective NSAIDs. The original WHO pain ladder states that adjuvant agents may be included with these nonopioid agents, but it does not name those agents.
What is the best treatment for neuropathic pain?
Pain with a neuropathic component may be effectively treated with anticonvulsants, such as pregabalin (Lyrica) and gabapentin. 14 More information on the identity and potential uses of such adjuvant agents should be included in Step 1 of an updated pain ladder.
What is leapfrogging over the middle step?
Another deviation allowed for leapfrogging over the middle step in the case of severe pain or breakthrough cancer pain, defined as a sudden, intense, short period of severe pain occurring against an ambient background of lower-level pain.
Why don't pain experts use the WHO pain ladder?
Most pain experts do not rely on the WHO pain ladder because it was not designed for highly complex cases, chronic nonmalignant pain and its complications, or crafting pharmacological regimens to fight multimechanistic pain.
When was the pain ladder first published?
When the WHO first published their pain ladder in 1986 , it offered guidance for clinicians around the world in treating cancer pain. 1 What made this simple diagrammatic ladder so enduring is the fact that it was intuitively understandable and could be immediately implemented anywhere in the world, including under-developed nations and regions with few pain specialists. A quarter century later, the use of the WHO pain ladder still offers effective and cost-effective pain relief for patients suffering from cancer pain, even those near end of life.
What is the WHO 3-step analgesic ladder?
The opioid epidemic challenges current attitudes toward pain management and necessitates the reexamination of the World Health Organization (WHO) 3-step analgesic ladder, introduced in 1986 for cancer pain management. Surgical treatment of pain is a logical extension of the original guideline, which is often absent in conversations with patients about treatment options for their pain and consequentially underutilized. However, with concerns growing regarding opioid use, a shift in the stepwise approach of the WHO analgesic ladder in an age of developing technology and surgical offerings could have profound implications for patients and public health. Surgical interventions potentially provide a long-term, cost-effective management strategy to reduce opioid use. This review canvasses surgical options, highlights literature on failed back surgery syndrome and spinal cord stimulation and reconsiders the current ladder approach to pain management.
What is the 3 step ladder?
Presented in 1986, the World Health Organization (WHO) analgesic ladder provided a framework for the stepwise medical management of cancer-related pain. 1 This 3-step ladder begins with nonopioid analgesics with or without nonpharmacological approaches for mild pain, continues with weak opioid medications (eg, codeine) with or without nonopioid analgesics and adjuvants for mild-to-moderate pain, and progresses to strong opioids (eg, oxycodone) with or without nonopioid analgesics and adjuvants for moderate-to-severe pain. 1 The American Pain Society’s identification of pain as the “fifth vital sign” in 1995 portended the increased importance of not only adequate treatment of pain in patients but also education of health care professionals. 2, 3 Eventually, a modified version of the 3-step ladder placed interventional pain management as a fourth step. 4, 5 Development of this algorithmic approach aimed to control refractory or intractable pain in both an efficient and a safe manner, providing a rational and balanced method to maximize pain relief while minimizing side effects and risks.
Is surgery a final step in pain management?
Despite advances, surgical treatments remain a final step in pain management, typically after all other approaches fail. 37 With concerns growing regarding complications of opioid use in an age of developing technology and surgical offerings, a paradigm shift in pain management away from the WHO analgesic ladder toward earlier surgical intervention could have profound implications for patients and public health. Over time, surgical procedures have become more precise, less invasive, and better understood and recognized by both patients and their physicians. The ethical dilemma of beneficence vs nonmaleficence is not limited to weighing the advantages and risks of surgery alone. The risks of surgery avoidance should also be considered, given that medical (“conservative”) treatments can cause tolerance, dependence, or clinical side effects, as seen with most analgesic regimens, opioid or otherwise. The possibility of long-term pain relief and associated increase in functionality and improvement in quality of life justifies surgery as an earlier treatment option, perhaps before opioids are introduced.
Is surgical treatment of pain a logical extension of the original guideline?
Surgical treatment of pain is a logical extension of the original guideline, which is often absent in conversations with patients about treatment options for their pain and consequentially underutilized.
Is percutaneous cordotomy safer than open cordotomy?
Due to cumulative surgical experience and advances in imaging techniques, the safety of surgery for pain has significantly improved. Percutaneous cordotomy with computed tomography (CT) guidance is safer than the open cordotomy of the 1950s. 10, 11, 12, 13, 14 Magnetic resonance imaging (MRI) guidance, together with intraoperative neurophysiological testing, increases accuracy of deep-brain stimulation targeting to a fraction of a millimeter. 15 Advancement from a single-contact electrode to 32-contact electrodes provides countless options for stimulation paradigms in cases of spinal cord stimulation. Thus, the prior argument that risk of surgery outweighed risk of opioid prescription, which previously predominated in the avoidance of surgical intervention for pain, no longer holds completely true, at least for neuromodulation.
When was the WHO 3 step ladder created?
The WHO 3-step ladder was devised in 1982 and officially adopted in 1986. 1-6 Although almost 30 years have passed since its adoption, it remains the pain treatment standard. It is not a specific opioid guideline but a template that provides a practical roadmap for pain treatment.
What is the WHO 3 step ladder?
In summary, the WHO 3-Step Ladder still is the standard template for treatment of cancer and non-cancer chronic pain. Opioids, weak or strong, are added, not substituted, to a regimen of non-opioid pharmacologic agents and adjuvants. The WHO 3-step ladder has endured for 30 years, simply because it gives the practitioner a practical protocol ...
How long has the WHO 3-step ladder been around?
The WHO 3-step ladder has endured for 30 years, simply because it gives the practitioner a practical protocol to follow that allows the provision of safe, effective, individualized treatment to countless patients.
What are the criticisms of the WHO 3-step ladder?
Criticisms of the 3-step ladder are that medications have changed since 1986 and that the ladder is too non-specific. 1-4 Thus, physicians reviewing the same patient could prescribe different treatment regimens despite using the same treatment template. A classic example of this phenomenon is the management of patients with neuropathic pain, for which some physicians use drugs (eg, anticonvulsants and anti-depressants) at Step 1 and others at Step 3. 6 I argue, as have others, that the lack of specificity within the WHO template is very positive and allows physicians great leeway to provide individualized care. 6
Is prolotherapy a non-opioid?
Corticoid injections and prolotherapy have adjunctive and non-opioid pharmacologic characteristics. A key element to the WHO 3-step ladder is that opioids are to be added to, not substituted for, an existing regimen of non-opioid pharmacologic agents and adjuvants.
Is Practical Pain Management a good site?
We are trying to spread the word to our readers that PracticalPainManagement.com, the Web site for Practical Pain Management, has a wonderful resource for patients. I invite all readers to visit our patient side, which contains basic information on a number of pain conditions and treatments, written by authors and Editorial Board Members of Practical Pain Management. This is an excellent resource for educating your patients about their disease and we encourage all readers to have their patients visit PracticalPainManagement.com/consumer to learn more.
Can non-opioid medications be switched?
Non-opioid medications and adjuvants can be added or switched at any step, but they must be an integral component of the treatment regimen. In my opinion, the recent crisis in opioid prescribing that has resulted in overdoses, diversion, and dosage escalation is, at least in part, the result of ignorance about the intent and execution ...
Introduction
Scope of Pain Problem
A New Paradigm in Pain Management
Better Understanding of Pain Emerging
Deploying The Pain Ladder in Clinical Practice
Discussion
Conclusion
- Over a quarter century after its publication, the WHO pain ladder is still an influential and practical guide for clinicians around the world for the management of cancer pain. So successful has been this simple ladder diagram that it has been used to help guide analgesia for noncancer pain syndromes as well. While we applaud the simplicity and pra...