Who Analgesic Ladder Revisited_profmrrajagopal
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WHO analgesic ladder
WHO analgesic ladder revisited M.R.Rajagopal MD [email protected] www.palliumindia.org
Advantages
Advantages
!
Simplicity
!
Applicability
Simplicity But oversimplified? ! Applicability
!
Safety
!
!
!
Emphasis on multimultimodal analgesia
!
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety !
!
Emphasis on multimultimodal analgesia
Safety Emphasis on multimultimodal analgesia
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety Are we sure? ! Emphasis on multimultimodal analgesia !
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety Are we sure? ! Emphasis on multimultimodal (within limitations) analgesia !
Simple? Ca prostate 10 years back, now recurred. Pain score 10 (0(0-10 scale) in penis - about 10 mts many times a day x 6 months. Has not had a good night’ night’s sleep in 6 months. Has often thought of suicide.
Management history when first seen by palliative care team !
Practically all NSAIDs (no response)
!
Flavoxate (no response)
!
Corticosteroids (no response)
!
Intravesical local anesthetics (no response)
!
Tramadol (no relief: very tired)
!
IV Morphine + lorazepam
WHY?
(no response; very drowsy)
Why is this man in pain?
Almost total relief… !
Initially oral probantheline tid
!
Later, oral oxybutinin tid
Irritation of trigone of bladder. Bladder spasms; pain referred to penis. What step of the ladder does he need?
He remains painpain-free after six months!
Advantages
Needed: Emphasis on assessment He needed proper adjuvants (step I of the ladder). Lack of appreciation of this resulted in failure of the
Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety !
!
ladder.
Universally applicable?
Young woman: advanced Ca breast with metastases
Ventafridda et al: Pain ↓ to 1/3 in 71%
1.
Good response to morphine; But in pain most of the time.
(Cancer 1987; 59:85059:850-856) 856) 2.
Zech et al: “Good” Good” pain relief in 76%
Psycho-social evaluation: pre-existing depressive illness; difficult family dynamics.
(Pain 1995; 63:6563:65-76) 3.
Colleau SM et al: Pain relief in 90% (Cancer Pain 1998; 11:111:1-5)
The ladder makes no provision for psychosocial elements? !
Look for clinical anxiety or depression
!
Look into insight about diagnosis & prognosis
!
Look for psychosocial problems Correct the correctable!
Emphasis on multimultimodal analgesia
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety Are we sure? ! Emphasis on multimultimodal analgesia !
Are non-opioids the safest? Is step 1 safer than steps 2 or 3? NSAIDs are more dangerous than opioids! !
Gastric perforation
!
Renal failure
!
Bleeding
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety Are we sure? ! Emphasis on multimultimodal (within limitations) analgesia !
How about physical measures, TENS, Acupuncture etc… etc…? There are many complementary measures which can be helpful. Ernst E et al; (2006). Review of 19 complementary measures: “Further research is warranted” warranted”. Support Care, Cancer 2006
Do we need step 2 of the ladder? Are step 2 opioids necessarily safer than step 3 opioids? Is 30 mg codeine safer or more effective than 3 mg of morphine? Perhaps not! The only reason for use of step 2 drugs might be regulatory barriers to step 3!
Where do interventional procedures come in? Would they form a step 4? Or steps beyond the ladder? Not necessarily. They may be relevant early on in the treatment. They may even form part of the “Adjuvants” Adjuvants” in step 1. At least think of them after step 3!
Psychosocial support Interventional procedures Physical measures; TENS Acupuncture; Music, Aroma therapy,…….
WHO analgesic ladder revisited M.R.Rajagopal MD [email protected] www.palliumindia.org
Advantages
Advantages
!
Simplicity
!
Applicability
Simplicity But oversimplified? ! Applicability
!
Safety
!
!
!
Emphasis on multimultimodal analgesia
!
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety !
!
Emphasis on multimultimodal analgesia
Safety Emphasis on multimultimodal analgesia
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety Are we sure? ! Emphasis on multimultimodal analgesia !
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety Are we sure? ! Emphasis on multimultimodal (within limitations) analgesia !
Simple? Ca prostate 10 years back, now recurred. Pain score 10 (0(0-10 scale) in penis - about 10 mts many times a day x 6 months. Has not had a good night’ night’s sleep in 6 months. Has often thought of suicide.
Management history when first seen by palliative care team !
Practically all NSAIDs (no response)
!
Flavoxate (no response)
!
Corticosteroids (no response)
!
Intravesical local anesthetics (no response)
!
Tramadol (no relief: very tired)
!
IV Morphine + lorazepam
WHY?
(no response; very drowsy)
Why is this man in pain?
Almost total relief… !
Initially oral probantheline tid
!
Later, oral oxybutinin tid
Irritation of trigone of bladder. Bladder spasms; pain referred to penis. What step of the ladder does he need?
He remains painpain-free after six months!
Advantages
Needed: Emphasis on assessment He needed proper adjuvants (step I of the ladder). Lack of appreciation of this resulted in failure of the
Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety !
!
ladder.
Universally applicable?
Young woman: advanced Ca breast with metastases
Ventafridda et al: Pain ↓ to 1/3 in 71%
1.
Good response to morphine; But in pain most of the time.
(Cancer 1987; 59:85059:850-856) 856) 2.
Zech et al: “Good” Good” pain relief in 76%
Psycho-social evaluation: pre-existing depressive illness; difficult family dynamics.
(Pain 1995; 63:6563:65-76) 3.
Colleau SM et al: Pain relief in 90% (Cancer Pain 1998; 11:111:1-5)
The ladder makes no provision for psychosocial elements? !
Look for clinical anxiety or depression
!
Look into insight about diagnosis & prognosis
!
Look for psychosocial problems Correct the correctable!
Emphasis on multimultimodal analgesia
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety Are we sure? ! Emphasis on multimultimodal analgesia !
Are non-opioids the safest? Is step 1 safer than steps 2 or 3? NSAIDs are more dangerous than opioids! !
Gastric perforation
!
Renal failure
!
Bleeding
Advantages Simplicity But oversimplified? ! Applicability To everyone in pain? ! Safety Are we sure? ! Emphasis on multimultimodal (within limitations) analgesia !
How about physical measures, TENS, Acupuncture etc… etc…? There are many complementary measures which can be helpful. Ernst E et al; (2006). Review of 19 complementary measures: “Further research is warranted” warranted”. Support Care, Cancer 2006
Do we need step 2 of the ladder? Are step 2 opioids necessarily safer than step 3 opioids? Is 30 mg codeine safer or more effective than 3 mg of morphine? Perhaps not! The only reason for use of step 2 drugs might be regulatory barriers to step 3!
Where do interventional procedures come in? Would they form a step 4? Or steps beyond the ladder? Not necessarily. They may be relevant early on in the treatment. They may even form part of the “Adjuvants” Adjuvants” in step 1. At least think of them after step 3!
Psychosocial support Interventional procedures Physical measures; TENS Acupuncture; Music, Aroma therapy,…….
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