The WHO Analgesic Step Ladder
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The WHO Analgesic Step Ladder. Strong opioid +/- NSAID +/- adjuvant. If pain is unrelieved on lower step, then progress up the ladder. STEP 3. Severe pain. Weak opioid+/- NSAID +/- adjuvant. Moderate pain. STEP 2. Paracetamol +/- NSAID +/- adjuvant. Mild-mod pain. STEP 1. Scenario.

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The WHO Analgesic Step Ladder

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The who analgesic step ladder

The WHO Analgesic Step Ladder

Strong opioid +/- NSAID +/- adjuvant

If pain is unrelieved on lower

step, then progress up the ladder

STEP 3

Severe

pain

Weak opioid+/- NSAID +/- adjuvant

Moderate pain

STEP 2

Paracetamol +/- NSAID +/- adjuvant

Mild-mod pain

STEP 1


Scenario

Scenario

A 38 year old woman with known glioblastoma stage 4

Recently underwent radiotherapy and is on a reducing course of dexamethasone

She comes to see you with headaches

What do you want to know?


The who analgesic step ladder

She has tried paracetamol up to 4 x daily

What do you want to know?

It is of no help

What do you do?


The who analgesic step ladder

She is given cocodamol 8/500 2 qds

No help

She is tried on codydramol 2 tabs qds

No help

She then is given dihydrocodeine 30-60mg qds

No help

She is tried on solpadol 2 tabs qds

No help

She then tries tylex 2 tabs qds

No help

What next?


The who analgesic step ladder

If someone needs an opioid what is the best one to start with?

What is a suitable starting dose?


The who analgesic step ladder

QUIZ:

What is the usual starting dose of oramorph?

Will she definitely take it? If not-why not?

Any thing you should routinely advise on, or even co-prescribe?


Quiz ctd

You give her some oramorph to supplement her regular cocodamol 30/500 2 tabs qds.

When do you plan to revisit symptom control? How?

Next week you find that:

she has taken 10mg oramorph 4 x in the last 24 hours

What do you want to know?

What next?

What do you prescribe/try for the next 24 hours?

QUIZ ctd


The who analgesic step ladder

  • Now she is on MST 30mg bd. What just in case dose of oramorph should she be on?


The who analgesic step ladder

QUIZ:

Now she is on MST 300mg bd. What just in case dose of oramorph should she be on?

How did she get from 30mg bd to 300mg bd?


Quiz ctd1

QUIZ ctd

You have a patient who is clearly dying. He is unable to manage oral medicine but in fact was on no analgesia. He is uncomfortable

Where do you start?

What if he had been comfortable?

What if he had been on 30mg MST bd?


The who analgesic step ladder

  • Write a prescription for the pain killer you want supplied (he was on MST 30mg bd prior to being unable to manage oral medication).

  • Write an authorisation so that a nurse can give him analgesia.


The who analgesic step ladder

  • What other medicines would it be sensible to supply?

  • For what symptoms?


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