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WHO Analgesic Ladder

This article discusses the WHO analgesic ladder at an advanced level and describes its relevance to acute pain management.

Learning outcomes
To understand the basis of the WHO analgesic ladder and its clinical application To recognise the limitations of the ladder and and have an understanding of alternative approaches to managing acute pain To understand the concept of multimodal analgesia and its importance in managing pain effectively and safely

WHO Analgesic Ladder

An analgesic is a member of the group of drugs which are used to relieve pain, also known as painkillers. The word analgesic derives from Greek an ("without") and algos ("pain"). The analgesic ladder was designed by the World Health Organisation (WHO) as a conceptual framework to assist in the prescription of analgesic drugs [1]. The ladder was initially introduced to improve the pain control of patients with cancer pain, however, it has lessons for the management of acute pain as it employs a logical strategy to manage pain. Hence today, it forms the basis of managing pain in the clinical environment. The ladder advocates a stepped approach to the use of painkillers from these analgesic groups: Non-opioid analgesics i.e. paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) Weak opioids i.e. tramadol, codeine Strong opioids i.e. morphine, fentanyl Adjuvants - adjuvant analgesics are drugs which were not originally for pain but rather for other conditions. They are a diverse group of drugs that includes antidepressants, anticonvulsants and others At every step of the analgesic ladder non-opioid analgesics form the basis of the pain management. Paracetamol and NSAID (if not contraindicated) should always therefore be prescribed with opioid analgesia (weak or strong). This is known as multimodal analgesia and is the concept that pain is best managed, not by a single drug or therapy, but by the combination of several analgesics to achieve more effective relief than analgesics administered individually. Evidence has demonstrated that when this happens pain relief is better, smaller amounts of pain killers are needed and less side effects occur. Most drugs induce analgesia through a single mechanism of action [2] however, clinical pain originates from multiple sources and often has different aetiologies. It has been proposed that through utilising this multi-modal approach of combining two or more analgesics with differing mechanisms of action, the efficacy of the overall analgesia can be dramatically increased [3]. A rigorous systematic review by McQuay & Moore [4] demonstrated that the combination of paracetamol and a NSAID with an opioid improves the efficacy of the treatment and also reduces adverse events associated with those individual treatments. The combination of paracetamol and NSAIDS with opioids has been shown to reduce the amount of opioids required to achieve the same effect by 20-30% [5]. This ideology is the basis of the WHO Analgesic Ladder and has subsequently informed best practice guidelines nationally.

Figure 1: WHO Analgesic Ladder The efficacy of the WHO analgesic ladder is reliant upon 5 simple recommendationsfor the correct use of analgesics being adhered to: 1. Oral administration of analgesics. The oral route for delivery of analgesics is preferable whenever possible. Obviously, in acute pain situations this is not always applicable, however, it is advised that once patients are able to tolerate oral medication that the route of administration is changed to this. 2. Analgesics should be given at regular intervals. To relievepain adequately, it is imperative that the efficacious duration ofthe analgesic is taken into account and to prescribe the dosageto be taken at definite intervals in accordance with the patientslevel of pain. 3. Analgesics should be prescribed according to pain intensityas evaluated by a scale of intensity of pain. As previously described in the pain assessment module analgesia should only be prescribed after a comprehensive assessment of pain (including a clinical examination) has been performed.The WHO analgesic ladder explicitly recommends that the analgesia be prescribed accordingto the level of thepatients pain utilising a valid pain tool. 4. Dosing of pain medication should be adapted to the individual. There is no standardized dosage in the treatment of pain as every individual will respond in a different way. The correct dosage is onethat willallow adequate relief of pain whilst causing minimal side effects. 5. Analgesics should be prescribed with a constant concern for detail. The regularity of analgesic administration is crucial for the adequate treatment of pain. Analgesics should be given by the clock, that is every 3-6 hours, rather than on demand. This stepped approach of administering the right drug in the right dose at the right time is inexpensive and generally effective in managing acute pain. The advantages of the analgesic ladder include: Simplicity, as only a few analgesic groups are used Flexibility to a large variety of pain situations and also to prescribers globally. By referring to drug classes, rather than specific drugs, the ladder maintains a level of flexibility that allows clinicians to work within their set regulations and limitations. Safety, in that safest drugs are used first in their lowest effective dose Emphasis on multimodal analgesia.

Its disadvantages include: It may be too simplistic for management of certain types of pain, especially neuropathic pain or for those who are opioid dependant. It suggests that analgesics should be administrated orally, which may occasionally not be appropriate, for example, post-operatively when patients are 'nil by mouth'. A modification of the WHO analgesic ladder was devised by the World Federation of Societies of Anaesthesiologists (WFSA) (Fig 2) which was specifically designed for the treatment of acute postoperative pain, burns, and trauma [6].The WFSA "acute pain treatment ladder" uses well-known and simple techniques of regional anaesthesia and a limited number of analgesics in a similar three-step approach. This ladder advocates starting at the 'top' when pain is known to be severe, or when it is predicted to be severe (post major surgery) and utilising a combination of strong opioids, non-opioid analgesics and regional techniques. As time progresses and the pain diminishes this approach advocates 'stepping down' the ladder.

Figure 2: The WFSA acute pain treatment ladder

References
1. Organisation W. Analgesic Ladder. World Health Organization; 1986. 2. Raffa RB, Clark-Vetri R, Tallarida RJ, Wertheimer AI. Combination strategies for pain management. Expert Opin Pharmacother. 2003;4:1697-708. 3. Puig M. Drug Combinations in pain management. Pain Europe. 2005;1:4-5. 4. McQuay HJ, Moore RA. An evidence-based resource for pain relief. Oxford: Oxford University Press; 1998. (Oxford medical publications). 5. Remy C, Marret E, Bonnet F. Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth. 2005;94:505-13. 6. Charlton JE. WFSA Update.. 1997;7:2-17. Acute Pain Pharmacology Secondary Care Advanced

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