____________________________________________ Assessment and Management of Pain at the End of Life
THE WORLD HEALTH ORGANIZATION’S THREE-STEP LADDER OF ANALGESIA
Step 3 Strong opioids +/- Non-opioids +/- Adjuvant analgesics
Severe pain (7-10 on a 10-point scale)
Step 2 Weak opioids +/- Non-opioids +/- Adjuvant analgesics
Mild-to-moderate pain (4-6 on a 10-point scale)
Mild pain (1-3 on a 10-point scale)
Step 1 Non-opioids +/- Adjuvant analgesics
Source: [31]
Figure 1
Strong opioids are the optimum choice of drug at Step 3. At any step, nonopioids and/or adjuvant drugs may be helpful. Some consider this model to be outdated and/or simplistic, but most agree that it remains foundational. It can be modi- fied or revised, as needed, to apply more accurately to different patient populations. The WHO ladder is also accompanied by five guiding prin- ciples [31]: • Reduce pain to levels that allow an acceptable quality of life. • Global assessment of the patient
lower doses in people with a history of alcohol abuse or renal or hepatic insufficiency [8]. NSAIDs are most effective for pain associated with inflam- mation. Among the commonly used NSAIDs are ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn), and indometha- cin (Indocin). There are several classes of NSAIDs, and the response differs among patients; trials of drugs for an individ- ual patient may be necessary to determine which drug is most effective [33]. NSAIDs inhibit platelet aggregation, increasing the risk of bleeding, and also can damage the mucosal lining of the stomach, leading to gastrointestinal bleeding. There is a ceiling effect to the nonopioid analgesics; that is, there is a dose beyond which there is no further analgesic effect. In addition, many side effects of nonopioids can be severe and may limit their use or dosing. Moderate pain (Step 2) has often been treated with analgesic agents that are combinations of acetaminophen and an opioid, such as codeine, oxycodone, or hydrocodone. However, it is now recommended that these combination drugs be avoided, as limits on the maximum dose of acetaminophen limits the use of a combination drug [8; 34]. Individual drugs in combi- nation is preferred, allowing for increases in the dose of the opioid without increasing the dose of the co-analgesic. Strong opioids are used for severe pain (Step 3). Guidelines suggest that the most appropriate opioid dose is the dose required to relieve the patient’s pain throughout the dosing interval without causing unmanageable side effects [4; 8; 26; 28; 30; 34; 36]. Morphine, buprenorphine, oxycodone, hydro- morphone, fentanyl, and methadone are the most widely used Step 3 opioids in the United States [35]. Unlike nonopioids, opioids do not have a ceiling effect, and the dose can be titrated until pain is relieved or side effects become unmanageable. For an opioid-naïve patient or a patient who has been receiving low doses of a weak opioid, the initial dose of a Step 3 opioid
should guide treatment, recognizing that individuals experience and express pain differently. • The safety of patients, carers, healthcare providers, communities, and society must be assured. • A pain management plan includes pharmacologic treatments and may include psychosocial and spiritual care. • Analgesics, including opioids, must be accessible: both available and affordable.
The pharmacologic treatment of pain involves selecting the right drug(s) at the right dose, frequency, and route, and managing side effects [8]. Nonopioid analgesics, such as aspirin, acetaminophen (Tyle- nol), and nonsteroidal anti-inflammatory drugs (NSAIDs), are primarily used for mild pain (Step 1 of the WHO ladder) and may also be helpful as coanalgesics at Steps 2 and 3. Acet- aminophen is among the safest of analgesic agents, but it has essentially no anti-inflammatory effect. Toxicity is a concern at high doses, and the maximum recommended dose is 3–4 g per day [8]. Acetaminophen should be avoided or given at
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MDNJ1525
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