Figure 6: WHO’s Pain Relief Ladder
Free from Cancer Pain
Opioid for moderate to severe pain +/- Nonopioid +/- Adjuvant
Opioid for mild to moderate pain +/- Nonopioid +/- Adjuvant Pain Persisting or Increasing
Pain Persisting or Increasing
Nonopioid +/- Adjuvant
Note. Image adapted from: http://www.who.int/cancer/palliative/ painladder/en/
Drugs used to treat mild pain There are two main drug types used to treat mild pain – acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs). These drugs are most effective in musculoskeletal pains and pain due to underlying inflammatory processes. Acetaminophen Acetaminophen is a widely used baseline analgesic drug. It can be obtained by prescription as well as over-the-counter (OTC). During an injury, chemical substances such as prostaglandins are being released into the bloodstream. These prostaglandins provoke pain response in the human body. Acetaminophen hinders the production of prostaglandins; thereby reduce the pain caused by the injury. Alternatively, acetaminophen acts upon the thermoregulatory area of the brain and lowers the body temperature [18] . Acetaminophen is available in various forms such as tablets, capsules, oral suspension, and suppositories. In some cases, it is combined with other drugs to enhance the effectiveness (e.g., Tylox, a more powerful pain reliever, is a combination of acetaminophen and oxycodone). Side effects of acetaminophen are very minimal compared with other drugs. However, there can be serious overdose reactions (e.g., hepatotoxicity, seizures, coma, and even death). Liver failure may result from long-term acetaminophen use. Table 1: Indications and Side Effects in Commonly Used NSAIDs Drug Dosage Indications
Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs provide pain relief and help reduce erythema, edema, and fever. Sprains, strains, headaches, joint pains (e.g., rheumatoid arthritis, osteoarthritis), and some infections can be treated by NSAIDs. These drugs block cyclooxyganase (COX) enzymes, specifically COX-2 enzymes, which promote pain and the inflammatory process by producing prostaglandins. Although they can provide pain relief, COX-2 inhibitors may lead to other health complications like indigestion and stomach ulcers. They may also induce the risk of cardiac diseases [19] . As the dosage of a drug increases, the effect of that drug progressively decreases by imperceptibly small amounts. This is the ceiling effect. When considering NSAIDs, the ceiling effect can be helpful because, though the drug dosage is increased, the analgesic effect does not change. Additionally, the severity of side effects and the risk of overdose increase with the increased dosage. NSAIDs cannot be used in pregnant or breast-feeding women, nor in patients with kidney disease, liver disease, and stomach ulcers. The dosage, indications, and side effects of some commonly used NSAIDs are shown in Table 1 [16][19][20] .
Side Effects
Aspirin
650mg (every 4 hours). 975mg (every 6 hours).
• Mild pain. • Fever. • Swollen, red & tender tissues. • Rheumatoid arthritis. • Rheumatic fever. • Mild pain. • Fever. • Swollen, red & tender tissues. • Rheumatoid arthritis. • Back pain. • Gout.
• Sensory problems. • Fluid imbalance. • Digestive problems.
• Drowsiness. • Fatigue. • Depression.
Ibuprofen (Advil, Motrin)
400–600 mg (every 6 hours).
• Headache. • Dizziness. • Thirst, sweating. • Ringing in the ears. • Blurred vision.
• Ankle swelling. • Numbness in hands & feet. • Abdominal pain.
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