WRITE A SHORT NOTE ON WHO ANALGESIC LADDER ?
10 MARKS
A 7 INTRODUCTION
1 Pain remains one of the main reasons for medical consultation worldwide.
2 1986 the World Health Organization (WHO) presented the analgesic ladder as a framework that physicians could use when developing treatment plans for cancer pain.
3 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
4 The WHO proposed the analgesic ladder following the recommendations of an international group of experts.
5 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.
6 The analgesic ladder proposed the use of a limited number of relatively inexpensive medications, such as morphine, in a stepwise approach.
7 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
CORNERSTONE OF WHO LADDER
1 The cornerstone of the WHO document rests on 5 simple recommendations for the correct use of analgesics to make the prescribed treatments effective.
2 This advice is applicable today, not only for cancer patients with pain, but also for all patients with either acute or chronic pain who require analgesics.
3 The 5 points for the correct use of analgesics are as follows:
1 Oral administration of analgesics - The oral form of medication should be privileged whenever possible.
2 Analgesics should be given at regular intervals.
A ) To relieve pain adequately, it is necessary to respect the duration of the medication’s efficacy and to prescribe the dosage to be taken at definite intervals in accordance with the patient’s level of pain.
B ) The dosage of medication should be adjusted until the patient is comfortable.
3 Analgesics should be prescribed according to pain intensity as evaluated by a scale of intensity of pain.
A ) This point is important because prescribed after clinical examination and adequate assessment of the pain.
B ) The prescription must be given according to the level of the patient’s pain and not according to the medical staff’s perception of the pain.
C ) If the patient says that he has pain, it is important to believe him.
D ) This point makes reference to the levels of the analgesic ladder that will be explained in detail further below.
4 Dosing of pain medication should be adapted to the individual.
A ) There is no standardized dosage in the treatment of pain.
B ) Every patient will respond differently.
C ) The correct dosage is one that will allow adequate relief of pain.
D ) The posology should be adapted to achieve the best balance between the analgesic effect and the side effects.
5 Analgesics should be prescribed with a constant concern for detail.
A ) The regularity of analgesic administration is crucial for the adequate treatment of pain.
B ) Once the distribution of medication over a day is established, it is ideal to provide a written personal program to the patient.
C ) In this way the patient, his family, and medical staff will all have the necessary information about when and how to administer the medications.
DISCUSSION
1 The 1986 version of the WHO analgesic ladder proposes that treatment of pain should begin with a nonopioid medication
2 If the pain is not properly controlled, one should then introduce a weak opioid.
3 If the use of this is insufficient to treat the pain then there should be use of strong opiod medication
4 one should never use 2 products belonging to same category
5 ADAPTATIONS TO ANALGESIC LADDER
A ) it includes inclusion of 4th step that is -
1 consideration of neurosurgical procedures such as brain stimulators
2 invasive techniques such as nerve blocks and neurolysis ( phenolization , alcoholization , thermocoagulation and radiofrequency )
3 other invasive techniques such as transforaminal epidural steroid injections , lumbar percutaneous adhesiolysis and spinal endoscopy for painful lumbar radiculopathy
4 new methods of administering opiods in the form of transdermal patches
6 ROLE OF ADJUVANT MEDICATIONS
It includes - steroids , anxiolytics , antidepressants , hypnotics , anticonvulsants , antiepileptic like drugs - gabapentin and cannabinoids
WHO LADDER - STEPWISE
STEP 1 ( FOR MILD PAIN ) - NON OPIOD ANALGESIC AROUND THE CLOCK SUCH AS - ACETAMINOPHEN 650 q 4hrly OR ASA 650 mg q 4hrly or IBUPROFEN 400 mg q 4hrly + / - ADJUVANTS
STEP 2 - ADDITION OF MILD OPIOD DERIVATIVE ALONG WITH NON OPIOD ANALGESIC ( FOR MODERATE PAIN ) AROUND THE CLOCK SUCH AS - ACETAMINOPHEN 325 mg + CODEINE 30 mg q 4hrly OR ACETAMINOPHEN 325 mg + CODEINE 60 mg q 4hrly OR ACETAMINOPHEN 325 / 500 mg + OXYCODONE 5 mg q 4hrly + / - ADJUVANTS
STEP 3 - ( FOR SEVERE PAIN ) - START STRONG ORAL OPIOD MEDICATION AROUND THE CLOCK SUCH AS - MORPHINE 5 TO 10 mg q 4hrly , DILAUDID 1 TO 4 mg q 4hrly + / - ADJUVANTS