PAIN LADDER Flashcards
1
Q
ANALGESIC LADDER?
A
- A STRATEGY PROPOSED BY THE WHO IN 1986
- GOAL TO PROVIDE ADEQUATE PAIN RELIEF TO CANCER PATIENTS
- LATER MODIFIED TO INCLUDE ACUTE AND CHRONIC NON-CANCER PAINFUL CONDITIONS
- PROVIDES A SIMPLE, PALLIATIVE APPROACH TOWARDS REDUCING MORBIDITY DUE TO PAIN IN 70-80% OF PATIENTS
2
Q
WHY DO WE NEED A PAIN LADDER?
A
- TO HAVE ADEQUATE KNOWLEDGE ABOUT PAIN
- TO ASSESS ITS DEGREE IN A PATIENT THROUGH PROPER EVALUATION
- TO PRESCRIBE APPROPRIATE MEDICATIONS
- TO BALANCE THE OPTIMUM DOSAGE WITH THE SIDE EFFECTS OF THE DRUG
- TO INCLUDE OPIOID ROTATION
- TO INCALCULATE PATIENT EDUCATION
3
Q
ORIGINAL WHO PAIN LADDER?
A
- HAD 3 STEPS, FROM MILDEST TO MOST SEVERE PAIN
STEP 1: MILD PAIN
- NONOPIOIDS (NSAIDs LIKE IBUPROFEN, NAPROXEN, ASPIRIN… & PARACETAMOL)
- ADJUVANT THERAPY (Adjuvant is a substance that enhances the immune system’s response to the presence of an antigen, e.g. ANTIDEPRESSANTS, GABAPENTIN, PREGABALIN, DIAZEPAM, DEXAMETHASONE)
STEP 2: MILD TO MODERATE PAIN
- WEAK OPIOIDS (E.G. TRAMADOL, CODEINE, COCODAMOL)
- NONOPIOIDS
- ADJUVANT THERAPY
STEP 3: MODERATE TO SEVERE PAIN:
- STRONG OPIOIDS (E.G. MORPHINE SULPHATE, AKA ORO MORPHINE, INTRAVENOUSLY, ORAL OXYCODONE, FENTANYL PATCHES..)
- NONOPIOIDS
- ADJUVANT THERAPY
–> ADJUVANT THERAPY CONTRIBUTES TO A MORE HOLISTIC APPROACH
4
Q
LIMITATIONS OF THE ORIGINAL WHO PAIN LADDER?
A
- UNIDIRECTIONAL (MOVING UPWARDS, FROM MILD TO SEVERE, NO STEPPING DOWN)
- 2ND LEVEL OF WEAK OPIOIDS SEEMED NON BENEFICAL (USING SMALL DOSES OF STRONG OPIOIDS SEEMS MORE BENEFICIAL)
- WAS SPECIFIC TO CANCER, WAS NOT ENOUGH TO MANAGE ACUTE AS WELL AS SPECIFIC LONG STANDING TREATMENT IN CHRONIC PAIN)
- DID NOT INCLUDE ANY NON-PHARMACOLOGICLA TREATMENTS
5
Q
NEW ADAPTATION OF THE ANALGESIC LADDER?
A
STEP 1: NONOPIOID ANALGESICS, NSAIDs
STEP 2: WEAK OPIOIDS
STEP 3: STRONG OPIOIDS, METHADONE, ORAL ADMINISTRATION, TRANSDERMAL PATCH
STEP 4: NERVE BLOCK, EPIDURALS, PCA PUMP, NEUROLYTIC BLOCK THERAPY, SPINAL STIMULATORS
- BIDIRECTIONAL!!! (IF A PATIENT EXPERIENCES TOXICITY OR RELIEF, TONING DOWN OF TREATMENT IS INDICATED)
- INTEGRATIVE THERAPY (YOGA, PSYCHOTHERAPY, ACUPUNCTURE..) AND ADJUVANTS CAN BE ADED AT ANY STAGE
- NSAIDs WITH OR WITHOUT ADJUVANTS CAN BE ADDED AT EACH STEP
- STEPS 3 AND 4 VERY INTERCHANGEABLE, ESPECIALLY IN THE CURRENT OPIOID CRISIS (E.G. WHEN SOMEONE HAS A HIP FRACTURE, THEY MIGHT BE OFFERED NERVE BLOCK INSTEAD OF STRONG OPIOIDS)
- ALLOWS DEALING WITH MALIGNANT AND NON MALIGNANT PAIN, CHRONIC AND ACUTE PAIN
6
Q
ADVANTAGES AND BENEFITS OF THE NEW ANALGESICS LADDER?
A
- WHO FOCUSED ON THE QUALITY OF LIFE AND WAS INTENDED AS A BIDIRECTIONAL APPROACH
- FOR ACUTE PAIN, THE STRONGEST ANALGESIC (FOR THAT INTENSITY OF PAIN) IS THE INITIAL THERAPY AND LATER TONED DOWN
- FOR CHRONIC PAIN, EMPLOYING A STEP-WISE APPROACH FROM BOTTOM TO TOP
- ORAL DOSING WHENEVER POSSIBLE AS OPPOSED TO E.G. INTRAVENOUS
- AROUND THE CLOCK ADMINISTRATION AS OPPOSED TO ON DEMAND
- ANALGESICS MUST BE PRESCRIBED ACCORDING TO PAIN INTENSITY AS EVALUATED BY A SCALE OF PAIN SEVERITY
- INDIVIDUALISED THERAPY (INCLUDING DOSING) ADDRESSES CONCERNS OF THE PATIENT
- PROPER ADHERENCE TO PAIN MEDICATIONS
7
Q
LIMITATIONS IN THE NEWLY ADAPTED VERSION OF THE ANALGESICS LADDER?
A
- LACK OF PROPER KNOWLEDGE OF DRUGS (ESP STROONGER OPIOIDS)
- UNDERDOSING AND WRONG TIMING OF DRUGS
- FEAR OF ADDICTION
- LACK OF PUBLIC AWARENESS AND EDUCATION REGARDING DOSES AND SIE EFFECTS OF DRUGS
- PLACEMENT OF DRUGS IN THE LADDER (E.G. NSAIDs ARE AT THE BOTTOM SO THEY MIGHT APPEAR AS THE SAFEST TREATMENT, BUT THEY HAVE THEIR SIDE EFFECTS, ESP IN SOME PATIENTS, E.G. THOSE WITH GI ISSUES)
- THE LADDER IS NOT EFFECTIVE IN COMPLEX CHRONIC PAIN ISSUES (E.G. NEUROPATHIC PAIN, FIBROMYALGIA)
8
Q
MULTIMODAL TROLLEY APPROACH
A
- BY LEUNG
- HOLISTIC/PERSONALISED APPROACH
- VISUALISED AS A TROLLEY WITH DRAWERS, EACH ONE CONTAINING A CERTAIN STRATEGY THAT CAN HELP IN PAIN RELIEF (E.G. OPIOIDS, CANNABINOIDS, ADJUVANTS, PHYSIOTHERAPY, RELAXING TECHNIQUES, PSYCHOLOGICAL SUPPORT…)
