“If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs – “adjuvants” – should be used.  To maintain freedom from pain, drugs should be given “by the clock”, that is every 3-6 hours, rather than “on demand” This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.”

The general principle in pain management is to start at the bottom rung of  the ladder, and then to climb the ladder if pain is still present. The medications range from household, over the counter drugs with minimal side-effects at the lowest rung to powerful opioids. Opioid usage carries a high risk of addiction and adverse effects if abused.

The Ladder 

Bottom rung of ladder (mild pain): Non opioid +/- adjuvant

Middle rung of ladder (moderate pain): Weak opioid +/- non opioid +/- adjuvant

Highest rung of ladder (severe pain): Strong opioid +/- non opioid +/- adjuvant

Definitions

1. Non opioid: aspirin, paracetamol (acetaminophen), non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac or ibuprofen

2. Weaker opioid: tramadol, codeine, dihydrocodeine

3. Strong opioid: morphine, diamorphine (heroin), fentanyl, buprenorphine, oxycodone, hydromorphone

4. Adjuvant: antidepressants, anticonvulsants, steroids, muscle relaxants, exercise, psychological support,
temperature therapy, primal therapy, hydrotherapy, acupuncture

References

External links

• Pain Ladder at the WHO
• wikipedia