WHO Ladder Gout Arthritis

WHO ANALGESIC LADDER
FOR PAIN MANAGEMENT

Dedi Susila
Relationship Between Pain, Sleep, and
Anxiety / Depression
Pain
Anxiety & Functional Sleep

Depression impairment disturbances
Response Cortical
- anxiety
- fear
- apprehension
Response Suprasegmental
- neurohumoral response
- catecholamines
- cortisol
- dll.
Response Segmental
- muclespasm
- vasospasm
- bronchospasm
- decreased gastrointestinal
motility
Response Local
-release pain substances
-inflammation
RESPONSES TO NOXIOUS STIMULI

The Biopsychosocial Model
Of
Pain Management
WHO Analgesic LADDER
WHO guidelines for the treatment of cancer pain
• It has been suggested that 90% to 95% of cancer pain
syndromes can be well controlled by using guidelines
established by the World Health Organization (WHO)
World Health Organization: Cancer pain relief and palliative care.1990
• 1995, Jadad et al
• 8 studies (1982-1995)
• adequate pain management in 69-100%’
• 2006, Ferriera et al
• 17 studies (8 overlap with earlier review)
• adequate pain management in 45-100 %
WHO Cancer pain relief principles
• Assessment pain severity is essential
• Started in appropriate level
• Analgesia given regularly
• Prescription for breakthrough pain
• Consider adjuvant drugs
• PCT and /or NSAIDs should be used at all step
• Morphine is the strong opioid choice
• Opioid rotation
5 phrases of 3-step ladder
1. By the mouth
2. By the clock
3. By the ladder
4. Individualized for the patient
5. Attention to detail
Paracetamol
• Analgesic antipyretic
• Used in all steps in Stepladder WHO
• Recommend dose 4000 mg/d
• Dose adjustment in hepatic dysfunction
NSAIDs
• Analgesic, antipyretic and anti-inflammatory
• Nonselective agents and selective COX-2 inhibitors
• Effective component in multimodal therapy
• Carefully selected patients due to adverse effect
• COX-2 inhibitors proveide protection adverse effect but concern in
Cardiovascular effect
Opioid
• Mainstay of cancer pain
• Multiple routes :
• Enteral
• Parenteral ( iv, sc )
• Spinal delivery
• Transdermal
• Transmucosal
• Several formulation :
• Strong opioid : morphine, fentanyl, pethidine, hydromorphone, oxycodone
• sustained release eg. MS Contin, Kadian, Avinza, Fentanyl patch, Hydromorphone,
Oxycodone SR
• Rapid release : MOIR
• Weak opioid : Codein and Tramadol
Principle in Opioid using
• Opioid titration
• Opioid rotation
• Opioid rescue
• Opioid sparring strategies
• Opioid side effect management
Opioid Titration Guidelines
• Titrate with short–acting hydrophilic opioid; can be given
at interval based on the time to peak serum level
as needed; oral ~ 1 hour , sc ~ 30 min, iv ~ 10 min.
• Calculate 24 hrs requirements and convert to long-acting opioid
Opioid Dose Escalation
Always increase by a percentage of the present dose based upon

patient’s pain rating and current assessment
50-100% increase
25-50% increase Severe pain

7-10/10
Moderate pain
4-6/10
Mild pain
1-3/10
Opioid Rescue Dose
Used for breakthrough pain.
Dose:
• Approximately 10% of daily dose equivalent.
Frequency :
• Oral every 1 - 2 hours
• Parenteral every 15 - 30 minutes
Opioid Rotation
Equianalgesic doses Opioids

Adjuvant analgesics
• Antidepressant
• Inhibition NE and serotonin reuptake
• For neurophatic pain
• Delays onset day to week
• Mood elevating and sleep enhancing effect
• Adverse effect on cardiac , glaucoma n prostatic
• Amitriptyline, Nortryptiline and Despiramine
• Anticonvulsant
• For neurophatic pain eg. Chemotherapy
• Na channel blocker : Carbamazepine and clonazepam
• Gabapentin : Ca Channel and can act as NMDA antagonist . 900 – 3600 mg/d
Adjuvant analgesic
• Corticosteroids
• Inhibit prostaglandin synthesis and reduce edema
• For neuropathic pain syndrome
• Bone pain , malignant intestinal obstruction
• Dexamethasone 12 – 24 mg once daily
• NMDA antagonist
• Bind EAA glutamat
• For severe neuropathic pain
• Routine use limited due to cognitive changes
Adjuvant analgesic
• Local anesthetic
• Inhibiting ions across neural membrane
• Relieving neuropathic pain
• Orally, topically, intravenously, subcutaneously, spinally
• For Intractable neuropathic pain :
Lidocaine intravenous 1 – 2 mg/kg ( max 500 mg ) over 1 hour then 1 -2 mg/kg/h
continuous infusion
WHO guidelines for the treatment of cancer pain
90% to 95% of cancer pain syndromes can be well

controlled by using WHO guidelines
But still…………
• 5% to 10% of patients are still suffering pain.
• So, what can be done to these patients?
When all else treatment fails….
We must look for alternative pain treatment
1. Alternative opioid delivery system
 Fentanyl patch, subcutaneous/IV infusion
2. Spinal drug delivery systems
 Spinal catheter, subcutaneous access port,implantable pumps
3. Nerve block with local anesthetics and steroids
4. Neurolytic blocks
 Alcohol or phenol
 Cryoanalgesia
 Radiofrequency destruction
Interventional pain management
A. The 3-step analgesic ladder developed by the World Health Organization. WHO. Cancer Pain Relief. Geneva: WHO; 1986.
B. The proposed 4th step.
Miguel R. Interventional Treatment of Cancer Pain : The Fourth Step in the World Health Organization
Analgesic Ladder ? Cancer Control 2000, 7 (2): 149-56.
KANKER PANGREAS
CELIAC NEUROLISIS
FLOUROSCOPY
GUIDED
"13 months after the procedure,
the patient passed away with dignity."
12 mounts after
pain intervention
Results: The WHO analgesic ladder for cancer pain is not appropriate
for current CNCP management. It is revised into a four-step ladder: the
integrative therapies being adopted at each step for reducing or even
stopping the use of opioid analgesics; interventional therapies being
considered as step 3 before upgrading to strong opioids if non-opioids
and weak opioids failed in CNCP management.
Choice of Analgesic Technique (Analgesic Ladder of WFSA)
for acute postoperative pain
Opiate Oral route available – give orally
Pain And
NSAID Oral route unavailable –
Intensity and Rectal paracetamol & NSAID Opiate:
High Tech: PCA
Paracetamol Low tech: IM algorithm Epidural
infusion analgesia
NSAID
and
Paracetamol
Pain Paracetamol
decreases as
time passes
Conclusion
The WHO analgesic ladder has become an essential tool for managing
cancer pain due to its ability to provide adequate relief while
minimizing risks associated with opioid use. Therefore, it is an
important part of any comprehensive cancer care plan and should be
used whenever possible to ensure optimal outcomes for patients
suffering from cancer pain.
THANK YOU

WHO Ladder Gout Arthritis

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WHO ANALGESIC LADDER

FOR PAIN MANAGEMENT

Anxiety & Functional Sleep

RESPONSES TO NOXIOUS STIMULI

Always increase by a percentage of the present dose based upon

25-50% increase Severe pain

Equianalgesic doses Opioids

90% to 95% of cancer pain syndromes can be well

Opiate Oral route available – give orally

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