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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.

The general principle is to start with first step drugs, and then to climb the ladder if pain is still present. The medications range from common, over-the-counter drugs at the lowest rung, to strong opioids.

The WHO guidelines recommend prompt oral administration of drugs ("by the mouth") when pain occurs, starting, if the patient is not in severe pain, with non-opioid drugs such as paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs (NSAIDs) including COX-2 inhibitors. Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, a weak opioid such as codeine, dihydrocodeine or tramadol is added to the existing non-opioid regime. If this is or becomes insufficient, a weak opioid is replaced by a strong opioid, such as morphine, diamorphine, fentanyl, buprenorphine, oxymorphone, oxycodone, or hydromorphone, while continuing the non-opioid therapy, escalating opioid dose until the patient is pain free or at the maximum possible relief without intolerable side effects. If the initial presentation is severe pain, this stepping process should be skipped and a strong opioid should be started immediately in combination with a non-opioid analgesic.


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