WHO analgesic ladder

WHO analgesic
ladder revisited
M.R.Rajagopal MD
pallium.india@gmail.com
www.palliumindia.org

Advantages Advantages
! Simplicity ! Simplicity
But oversimplified?
! Applicability ! Applicability

! Safety ! Safety

! Emphasis on multi-
multi- ! Emphasis on multi-
multi-
modal analgesia modal analgesia

Advantages Advantages
! Simplicity ! Simplicity
But oversimplified? But oversimplified?
! Applicability ! Applicability

To everyone in pain? To everyone in pain?

! Safety ! Safety

Are we sure?
! Emphasis on multi-
multi- ! Emphasis on multi-
multi-
modal analgesia modal analgesia
 Advantages Simple?

! Simplicity Ca prostate 10 years back, now recurred.

But oversimplified?
Pain score 10 (0-
(0-10 scale) in penis - about
! Applicability

To everyone in pain? 10 mts many times a day x 6 months.

! Safety Has not had a good night’
night’s sleep in 6
Are we sure? months.
! Emphasis on multi-
multi-
modal (within Has often thought of suicide.
limitations) analgesia

Management history when first

seen by palliative care team

WHY?
! Practically all NSAIDs (no response)
! Flavoxate (no response)
! Corticosteroids (no response)
! Intravesical local anesthetics (no response)
! Tramadol (no relief: very tired)
! IV Morphine + lorazepam
(no response; very drowsy)

Why is this man in pain? Almost total relief…

! Initially oral probantheline tid

Irritation of trigone of bladder.
! Later, oral oxybutinin tid
Bladder spasms; pain referred to penis.
He remains pain-
pain-free after six
What step of the ladder does he need?
months!
Needed: Emphasis on assessment Advantages
He needed proper ! Simplicity
adjuvants (step I of But oversimplified?
! Applicability
the ladder).
To everyone in pain?
Lack of appreciation
! Safety
of this resulted in
failure of the ! Emphasis on multi-
multi-
ladder. modal analgesia

Young woman: advanced Ca breast

Universally applicable?
with metastases
1. Ventafridda et al: Pain ↓ to 1/3 in 71% Good response to morphine;
(Cancer 1987; 59:850-
59:850-856)
856) But in pain most of the time.
2. Zech et al: “Good”
Good” pain relief in 76%
(Pain 1995; 63:65-
63:65-76) Psycho-social evaluation:
3. Colleau SM et al: Pain relief in 90% pre-existing depressive illness;
(Cancer Pain 1998; 11:1-
11:1-5)
difficult family dynamics.

The ladder makes no provision

Advantages
for psychosocial elements?
! Simplicity
! Look for clinical anxiety or depression But oversimplified?
! Look into insight about diagnosis & ! Applicability

prognosis To everyone in pain?

! Safety
! Look for psychosocial problems Are we sure?
Correct the correctable! ! Emphasis on multi-
multi-
modal analgesia
 Are non-opioids the safest? Do we need step 2 of the ladder?

Is step 1 safer than Are step 2 opioids necessarily safer than

steps 2 or 3? step 3 opioids?
NSAIDs are more
Is 30 mg codeine safer or more effective
dangerous than
opioids! than 3 mg of morphine? Perhaps not!
! Gastric perforation The only reason for use of step 2 drugs
! Renal failure might be regulatory barriers to step 3!
! Bleeding

Advantages Where do interventional

procedures come in?
! Simplicity
But oversimplified? Would they form a step 4? Or steps
! Applicability beyond the ladder?
To everyone in pain? Not necessarily. They may be relevant
! Safety early on in the treatment.
Are we sure? They may even form part of the
! Emphasis on multi-
multi- “Adjuvants”
Adjuvants” in step 1.
modal (within At least think of them after step 3!
limitations) analgesia

How about physical measures,

TENS, Acupuncture etc…
etc…? Psychosocial support
Interventional procedures
Physical measures; TENS
There are many complementary measures Acupuncture; Music, Aroma therapy,…….

which can be helpful.

Ernst E et al; (2006). Review of 19
complementary measures: “Further
research is warranted”
warranted”.
Support Care, Cancer 2006