Using the world health organization who analgesic ladder in. Prevalence of analgesic use amongst university students 776 p j m h s vol. Usefulness of the second step in the who analgesic ladder has been questioned by some experts. The who stratified three steps in this approach of analgesic drugs. The analgesic ladder remains the mainstay of our approach to analgesia, although it was not designed for use in isolation. The world health organization who is a specialized agency of the united nations that is concerned with international public health.
Neuromuscular blocking or paralytic agents cannot be used without general anaesthesia. The who analgesic ladder for cancer pain control, twenty years of use. The who analgesic ladder provides a general guide to pain management. Example of use of the who analgesic ladder patient on no analgesics mild pain choice of initial analgesic should take into account the cause and severity of pain. Delphi study who pain guidelines world health organization. Pain specialists and hospice staff, however, think about pain differently, and examining pain in this way can help pharmacists discuss pain with patients. Frequency of analgesic usage frequency n %age daily 15 8 weekly 40 21 fortnightly 30 15. Some scales are based solely on faces 6, and the apls pain ladder combines objective and subjective descriptions with panda faces 7. Tcas offer arthritis patients an analgesic benefit apart from their antidepressive effects. The world health organization threestep analgesic ladder comes of age. See also separate end of life care, palliative care and prescribing in palliative care articles. Sharon wood msc, dip healthcare research studies, ihbc body massage, rgn, is lecturer in nursing, university of leeds.
The analgesic ladder approach suggests that, with increasing reported pain intensity, increasingly strong analgesics should be provided and doses of strong opioids increased until pain is controlled, but goodquality evidence to support the longterm use of opioids in noncancer pain is lacking. The word analgesic derives from greek an without and algos pain. Our mistake is to treat chronic pain as if it were acute or end of life pain in 1986, the world health organization who developed a simple model for the slow introduction and upward titration of analgesics, which became known as the who analgesic stepladder. Use who analgesic ladder step 1 paracetamol, step 2 weak opioids step 3 morphine ir 2 to 5mg 2 to 4 hourly and titrate convert to morphine mr. The pain ladder contains objective and subjective descriptions with a numerical scale. It is a recognized risk factor for early death in hbss patients above the age of 20 years platt et al, 1994. 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. In general, at step one, paracetamol and nsaids are recommended. Numerous organizations and scientific associations have made efforts to find solutions for this problem and to facilitate the treatment of pain.
For management of cancer pain 2006 myeloma academy. Managing low back pain in primary care australian prescriber. Dec, 2012 the use of tcas in arthritis has found such a wide distribution that it has been proposed that these agents along with anticonvulsants should be described as painmodifying drugs. At step two weak opioids are introduced and at step three the weak opioid is stopped and a strong opioid started. Analgesic definition of analgesic by medical dictionary. 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. It was established on 7 april 1948, and is headquartered in geneva, switzerland. 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 the general principle is to start with first step drugs, and then to climb the.
For moderate pain start at step 2 or step 3 see section below re weak opioids. Pain ladder acute pain guidance on analgesic choice for noncancer acute pain pharmacology in pain management physiopedia. Regional anaesthetic or analgesic blocks can be performed by either an anterior or posterior approach to achieve optimum analgesia. Its predecessor, the health organization, was an agency of the league. The who analgesic ladder there are three steps on the ladder. Mar 23, 2016 professional reference articles are designed for health professionals to use. Nsaids have a role at all stages of the analgesic ladder if there is an inflammatory. Organisation who pain ladder and relevant guidance. Pain management in the long term care setting clinical.
Welsh medicines resource centre wemerec 03 february 2017 breakthrough andor incident pain. Mar 30, 2015 acute chest syndrome remains a leading cause of premature mortality in scd. Nonsteroidal antiinflammatory drugs nsaids should be avoided where possible renal effects and gastric irritation. May 03, 2012 the world health organization analgesic ladder was established over 20 years ago in order to direct the management of cancer pain. This league table was constructed for analgesics in acute pain. In the uk, there is a wide range of opioids available table 3. The annual indirect productivity cost of back pain in the uk was. The initial choice of weak, moderate, or strong opioid is determined after careful assessment of the individual patient. Clinical guidelines for symptom control in patients with. Analgesic prescribing in palliative care british journal. This ladder represents a sequential approach, with morphine and other strong opioids being the predominant pharmaceutical agents used in the management of moderate to severe pain. Approximately 25% of australians suffer from low back pain and about half of those seek care. Jan 16, 2017 the analgesic ladder approach suggests that, with increasing reported pain intensity, increasingly strong analgesics should be provided and doses of strong opioids increased until pain is controlled, but goodquality evidence to support the longterm use of opioids in noncancer pain is lacking.
You may find one of our health articles more useful. A collaborative working group consisting of members representing the european society for paediatric urology espu and the european association of urology eau has prepared these guidelines with the aim of increasing the quality of care for children with urological conditions. In 1986, the world health organization who developed a simple model for the slow introduction and upward titration of analgesics, which became known as the who analgesic stepladder. Who analgesic ladder proposed in 1986 has been the cornerstone of pain management, but. The who analgesic ladder for cancer pain control, twenty. The who 3step ladder has endured for 30 years, simply because it gives the practitioner a practical protocol to.
They are written by uk doctors and based on research evidence, uk and european guidelines. The world health organization threestep analgesic ladder comes of age show all authors. This briefing paper specifically considers the need to improve analgesic use to support pain management at the end of life. The world health organization threestep analgesic ladder comesofage eighteen years ago, the world health organization who published a document entitled cancer pain relief, which set out the principles of cancer pain management based on the use of a threestep analgesic ladder. In 1986 the world health organization who presented the analgesic ladder as a framework that physicians could use when developing treatment plans for. Analgesic drugs act in various ways on the peripheral and central nervous systems. General instructions cardiovascular research oxford academic. The analgesic ladder, which was promulgated by the world health organization in the late 1980s, was the first guideline to codify an opioidbased treatment for cancer pain. There are several different opioid options that can be considered at step two of the who analgesic ladder for chronic pain. Commonly used opioid analgesics compared to morphine. Strategies to reduce or eliminate wound pain nursing times.
Pharmacy staff often categorize pain using traditional models. This can sometimes lead to harm rather than benefit from a particular treatment. Retain more information using thousands of charts, xrays and images with digital overlays that illustrate key diagnostic points, structures and systems. Analgesic use in renal failure st elizabeth hospice ipswich. Surgery, radiotherapy, and appropriate tumoricidal treatments have an important role in some patients, as will nondrug treatments.
Nov 20, 2010 pain assessment is an essential part of postoperative care. Pain essential pain management home faculty of pain. Many thanks to michael oconnor united kingdom, maurice hennessy australia, ramesh menon new zealand, muralidhar joshi and palanisamy vijayanand india, and carolina hayock loor honduras for their help with preparation of the second edition. In summary, the who 3step ladder still is the standard template for treatment of cancer and noncancer chronic pain. Opioids, weak or strong, are added, not substituted, to a regimen of nonopioid pharmacologic agents and adjuvants. Rcem recommends the use of the attached assessment tool or a locally developed alternative. Studies that used the original who analgesic ladder for cancer pain control were eligible for inclusion see other publications of related interest nos. The analgesic ladder was designed by the world health organisation who 1 to assist the healthcare prescriber in the prescription of analgesic drugs by suggesting a logical strategy for managing pain in a multitude of pain situations. The ladder advocates a stepped approach to the use of painkillers from these analgesic groups. View the article pdf and any associated supplements and figures for a period of 48 hours. Fons2012internationalpracticedevelopmentjournal2 26 4 pressureamericangeriatricsociety,2002. An analgesic or painkiller is any member of the group of drugs used to achieve analgesia, relief from pain.
The regimen considered in a parallel manner the severity of pain and the presumed efficacy of analgesics. The world health organisation who analgesic ladder is the framework used to guide the pharmacological treatment of pain in chronic pain and palliative care patients. The original fulltext guideline provides an algorithm on pain management in the long term care setting to be used in conjunction with the written text. The term chronic pain is used throughout this document and refers to a continuous pain that persists beyond the expected time of healing or for longer than 3 months excluding cancer related pain and pain experienced at the end of life care. The 1986 version of the who analgesic ladder proposes that treatment of pain should begin with a nonopioid medication figure 1. Gmmmg%20neuropathic%20pain%20guidance%20march%202014.
There are different types of analgesics, including. How can we assess pain in people who have difficulty. Offer corticosteroids and analgesia and consider spinal stability while the patient is assessed. Magnetic resonance imaging of the whole spine is the investigation of choice. By the ladder by the clock by the appropriate route by the individual zthree step analgesic ladder zobsolete now for some recommended opioids e. Guideline on the management of acute chest syndrome in sickle. In the included studies, all analgesics were associated with adjuvant drugs.
Palliative care pain and symptom control guidelines nhs england. Sign 6 management of chronic pain scottish intercollegiate. This should be increased to the maximum dose of 1 gram four times a day, before switching. Timely referral for neurosurgery or radiotherapy, or both. Pain ladder acute pain guidance on analgesic choice for noncancer acute pain uk ltd and developed in partnership with guidelines in practice. The world health organization analgesic ladder miller. They are distinct from anesthetics, which temporarily affect, and in some instances completely eliminate, sensation. Nonopioids for mild pain, with or without adjuvants step 1 uses simple nonopioids e.
A combined approach can lead to optimum analgesia with minimum side. Traditionally serum creatinine has been used as a measure of renal function. May 19, 2016 metastatic spinal cord compression is an oncological emergency and may be the first presentation of a cancer. Nonsteroidal antiinflammatory drugs nsaids are the most frequently prescribed medicines for analgesia in primary care, after paracetamol. Barakzoy as, moss ah 2006 efficacy of the world health organization analgesic ladder to treat pain in. For investigations involving procedures with animals or isolation of animal tissues, the methods section must provide the generic name of the anaesthetic and analgesic agents used.
Choice of drug, after contraindicated drugs are excluded, comes down to a balance between possible adverse effects and the desired analgesic effect. Brown a 2014 strategies to reduce or eliminate wound pain. If the use of this medication is insufficient to treat the pain, one can begin a more powerful opioid. Low back pain is a common and costly condition in australia. World health organization who analgesic ladder the three main principles of the who analgesic ladder are. Get clues for approaching the questions, and develop skills not just in finding correct answers but in creatively defining your solutions. Evidence context medicines optimisation in chronic pain. To maintain freedom from pain, drugs should be given by the clock or around the clock rather than only on demand i.
The world health organization threestep analgesic ladder. This is inaccurate as patients may have a clinically significant deterioration in renal function while still having a serum creatinine within the normal reference range. These drugs can be sold as an overthecounter otc or prescription drug. Pain not controlled by pain ladder contact acute pain team. Originally developed by the world health organisation who to improve management of cancer pain. Annemarie brown is nursing lecturer, bsc adult nursing, department of health and human sciences, university of essex, southend on sea. Numbers needed to treat are calculated for the proportion of patients with at least 50% pain relief over 46 hours compared with placebo in randomised, doubleblind, singledose studies in patients with moderate to severe pain. Analgesic ladder for management of cancer pain 2006 oup unless otherise noted ohibited. Note from the american medical directors association amda and the national guideline clearinghouse ngc. Pain management in palliative care contents 4 professor rod macleod lessons learned 5 pain in palliative care 6 pain assessment in palliative care 10 strategies for total pain management the who analgesic ladder. Is longterm paracetamol use not as safe as we thought. The who is a member of the united nations development group. In a recent national survey in the united kingdom, acs was the third most common cause of death reported in adults lucas et al, 2008.