General

Chronic Pain Management: WHO Three-step Ladder Approach

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29 Aug 2016 - General
 

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The World Health Organization has released a three-step ladder approach to cancer pain in 1986. As the practice of medicine has elvolved three decades after the initial release, it is now used not only for cancer pain but also for chronic pain to other chronic illnesses. The stepladder approach is a good guide to ensure that the patient gets sufficient analgesia, especially in the emergency room setting. A doctor must always ask the pain intensity using the pain scale (1-10) in order to be guided with this approach. Here are the segments of the three-step ladder analgesia recommendation:

Step 1 ( for Mild pain with 1-3 intensity) - use Acetaminophen q6 and NSAIDs BID to TID plus an adjuvant (such as muscle relaxant [ for spasms] or anticonvulsant [for radiculopathy] )

Step 2 ( for Moderate pain with 4-6 intensity) - use a weak opiod q6 - q8 plus medications in  step 1

Step 3 ( for Severe pain with intensity of 7 and above) - repalce weak opioid with a stronger opioid plus medications in step 1 given round the clock

This has been really helpful in pain management for our practice. Are you using the same guidelines for pain management in your practice? Do you find the three-step ladder approach effective for chronic pain cases?

Jennifer Winter The sad thing about the medicine hoarders is that they really go doctor shopping to get prescription drugs. It is just a matter of time before a medical term is coined for them. "I don't want them leaving the clinic disappointed after all" There is something with our fellow countrymen that makes them feel shortchanged if no medication is prescribed. Even offering physical modalities ...
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Mark Edmon Tan " Oh those dear medicine hoarders"- yes that is the perfect term to describe them. They try but I do my best to explain to them that I am doing this for their own good. I don't want them leaving the clinic disappointed after all. Thank you for sharing your pain management plan with Paracetamol. This drug is not receiving the love that it should. We can't hold it against patients t...
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Jennifer Winter I get the same reactions with Paracetamol. Patients get skeptical when I prescribe it and I even get the comment "Doctor, I think paracetamol's use is for fever (in the vernacular)." For the NSAID and opioid naive patients, paracetamol can address their pain symptoms without requiring an adjuvant NSAID. It works great too for tension headache and delayed onset of muscle soreness from...
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Mark Edmon Tan Indeed we are :). Yes I agree with believing the patient's reported pain scale as it is very subjective. Something that causes a pain rating scale of 3 to some could be an 8 for others. Pain tolerance depends on the individual and certain pain medications cannot relieve the pain. Paracetamol is a good starter medication and it does help with pain relief for a good number of patients. There are ...
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Jennifer Winter Seems like we were at the same thought process haha. That is a great thing to point out. Pain is very subjective and depends on the patient's threshold. There are really patients who look calm but are in severe pain. For me, I usually believe the patient's reported pain scale because they are the ones that feel the symptom. I respect their rating enough to give them the appropriate symptom...
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Mark Edmon Tan: I believe we were typing up our comments around the same time. In terms of pain medication switching or mere prescribing of the medicine this one is the one I uphold the most: "Patient does not experience pain relief or improve functionality with performing ADLs". I always tell patients when what you are experiencing interferes with your normal daily functioning it is a problem and it ne...
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Yes this step ladder approach has been deemed very useful outside the realm of cancer patients. As Theekshana Abayawickrama said it ensures that we do not over treat patients. Since this is for chronic pain patients the chronicity of their pain needs to be established as they could be addicts. I say addict because a person who is really in chronic pain and is drug dependent should not be called an addict as they t...
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Theekshana Abayawickrama That is sad to hear for chronic drug addicts. They even feign illness just to use tramadol as their "fix". It is good that you guys are really discerning with prescribing pain medications. We have junkies here too who try to tell what medication to prescribe. Speaking of addiction, pain management outcomes have 4A's to monitor: Analgesia, ADLs, aberrant drug taking, and adver...
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'The stepladder approach is a good guide to ensure that the patient gets sufficient analgesia' And it also ensures that patients are not over treated with pain medications. A patient coming with the complain of severe pain may not always require opioid analgesics. We can try simple analgesics first like PCM and NSAIDs before stepping up. In the previous hospital I worked, we used to get chronic drug addicts faking severe pain. When they run out of money to do drugs, and withdrawal sympto...
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