Is the WHO analgesic ladder
still valid?
Dr. Grisell Vargas-Schaffer
Pain center at CHUM
University of Montreal
Canada
All my apologies for the damage to the language
of Shakespeare in the presentation
Thank you for your understanding......
Conflict of interest
Research
funds
Conferences
Astra Zeneca
Bayer
Jansen-Ortho
Services: travel
expenses,
accommodation
Medical Advisory
Lille
Merck Frosst
Pfizer
Purdue Pharma
x
x
Moral commitment
If, in my presentation I suggested off-label for a drug,
I agree to inform the audience.
I agree to use as far as possible, the pharmacologic
terminology instead of brand names.
Objectives of the presentation
To know the application of the WHO
analgesic ladder in chronic and acute pain.
To show how to surf the analgesic ladder.
To know how to position the patient at the
center of the pain control strategy.
Chronic pain
Rodin 1898
Pain remains one of the main reasons for
medical consultation worldwide.
In todays society, chronic pain is justly
regarded as a disease and a social health care
problem.
Chronic pain
Rodin 1898
Statistics from the Canadian Pain Coalition
indicate that 30% of Canadians suffer from
chronic pain, which can impact all areas of a
person's life, mind, body and spirit.
Those who suffer from pain often face
challenges in their efforts to find pleasure and
meaning in their lives.
Finding that pain management is
inadequate in most of the world
There is inadequate access to treatment for acute
pain caused by trauma, disease, and terminal illness
and failure to recognize that chronic pain is a serious
chronic health problem requiring access to
management akin to other chronic diseases such as
diabetes or chronic heart disease.
There are major deficits in knowledge of health care
professionals regarding the mechanisms and
management of pain.
IASP 2010 Montreal
Finding that pain management is
inadequate in most of the world
Chronic pain with or without diagnosis is highly
stigmatized.
There are severe restrictions on the availability of
opioids and other essential medications, critical to
the management of pain.
Most countries have no national policy at all or very
inadequate policies regarding the management of
pain as a health problem, including an inadequate
level of research and education.
IASP 2010 Montreal
Finding that pain management is
inadequate in most of the world
Pain Medicine is not recognized as a distinct
specialty with a unique body of knowledge and
defined scope of practice founded on research and
comprehensive training programs.
The World Health Organization (WHO) estimates
that 5 billion people live in countries with low or no
access to controlled medicines and have no or
insufficient access to treatment for moderate to
severe pain.
IASP 2010 Montreal
Declaration of Montreal
Declaration that Access to Pain Management Is
a Fundamental Human Right
Declaration that Access to
Pain Management Is a
Fundamental Human Right
Article 1. The right of all people to have access to
pain management without discrimination.
Article 2. The right of people in pain to the
acknowledgment of their pain and to be informed
about how it can be assessed and managed.
Article 3. The right of all people with pain to have
access to appropriate assessment and treatment of
the pain by adequately trained health care
professionals.
IASP 2010 Montreal
TREATMENT OF PAIN
Pharmacological
Invasive treatment
Drugs
Non Pharmacological
The correct use of analgesics to
make the prescribed treatments
effective
1. Oral administration of analgesics.
2. Analgesics should be given at regular
intervals.
3. Analgesics should be prescribed according to
pain intensity as evaluated by a scale of
intensity of pain.
4. Dosing of pain medication should be adapted
to the individual.
5. Analgesics should be prescribed with a
constant concern for detail.
The correct use of analgesics to
make the prescribed treatments effective
1.
Oral administration of analgesics.
2. Analgesics should be given at regular
intervals.
To relieve pain adequately, it is necessary to respect
the duration of the medications efficacy
To prescribe the dosage to be taken at definite
intervals in accordance with the patients level of pain.
The dosage of medication should be adjusted until
the patient is comfortable.
The correct use of analgesics to
make the prescribed treatments effective
1.
2.
Oral administration of analgesics.
Analgesics should be given at regular intervals.
3. Analgesics should be prescribed according to
pain intensity as evaluated by a scale of
intensity of pain.
The prescription must be given according to the level
of the patients pain and not according to the medical
staffs perception of the pain.
If the patient says that he has pain, it is important to
believe him.
The correct use of analgesics to
make the prescribed treatments effective
1.
2.
Oral administration of analgesics.
Analgesics should be given at regular intervals.
3.
Analgesics should be prescribed according to pain intensity as evaluated by a scale of intensity of pain.
4. Dosing of pain medication should be adapted to the
individual.
There is no standardized dosage in the treatment of pain.
Every patient will respond differently.
The correct dosage is one that will allow adequate relief of
pain.
The posology should be adapted to achieve the best
balance between the analgesic effect and the side effects.
The correct use of analgesics to
make the prescribed treatments effective
1.
2.
3.
4.
Oral administration of analgesics.
Analgesics should be given at regular intervals.
Analgesics should be prescribed according to pain intensity as evaluated by a scale of
intensity of pain.
Dosing of pain medication should be adapted to the individual.
5. Analgesics should be prescribed with a
constant concern for detail.
Once the distribution of medication over a day is
established, it is ideal to provide a written
personal program to the patient.
In this way the patient, his family, and medical
staff will all have the necessary information about
when and how to administer the medications.
The 1986 version of the WHO
analgesic ladder
1. World Health Organization. Geneva, Switz: World Health Organization; 1987.
The 1986 version of the WHO
analgesic ladder
If the pain is not properly controlled, one should
then introduce a weak opioid.
If the use of this medication is insufficient to treat
the pain, one can begin a more powerful opioid.
One should never use 2 products belonging to
the same category simultaneously.
The analgesic ladder also includes the
possibility of adding adjuvant treatments for
neuropathic pain or for symptoms associated
with cancer.
World Health Organization. Traitement de la douleur cancreuse. Geneva, Switz: World Health Organization; 1987.
World Health Organization. Traitement de la douleur cancreuse. Geneva, Switz: World Health Organization; 1997.
WHO analgesic ladder
WHO analgesic ladder
Only in cancer pain
Some believe that beginning step by step
is often insufficient and inefficient for
controlling intense pain
New treatment and drugs
The adaptation of the analgesic
ladder for acute pain,
chronic noncancer pain, and
cancer pain
Neurosurgical
Procedures
Acute pain
Chronic pain without control
Acute crises of chronic pain
STEP IV
STEP III
STEP II
Nerve block
Epidurals
PCA
Neurolytic block
Spinal stimulators
Strong Opioids
Weak opioids
STEP I
Non opioid
Analgesics
NSAID
Chronic pain
Non malignant
And Cancer pain
NSAID
+/- Adjuvants at each step
Vargas-Schaffer G Canadian Family Physician Le Mdecin de famille canadien Vol 56: june juin 2010
STEP IV
Neurosurgical
Procedures
Acute pain
STEP III
Chronic pain without control
Acute crises of chronic pain
STEP II
STEP I
Nerve block
Epidurals
PCA
Neurolytic block therapy
Spinal stimulators
Weak opioids
Non opioid
Analgesics
NSAID
Strong Opioids
Methadone
Oral administration
Transdermal patch
Chronic pain
Non malignant
And Cancer pain
NSAID
+/- Adjuvants at each step
PCA (Patient Controlled Analgesia)
NSAID: Non Steroidal Anti-Inflammatory Drugs
G. Vargas-Schaffer. Is the WHO analgesic ladder still valid?: Twenty-four years of experience Can Fam Physician 2010;56:514-7
Multimodal Analgesia
Association of different drugs
Different mechanisms of action
Use of lower doses
Reduction of side effects
Pharmacological synergy
STEP I
WHO analgesic ladder (proposed)
Paracetamol
Acetaminophen
NSAID
STEP II
WHO analgesic ladder (proposed)
Tramadol
Tapetandol
Buprenorphine
Codeine
STEP III
WHO analgesic ladder (proposed)
Morphine
Oxycodone
Hydromorphone
Fentanyl
Methadone
STEP IV
WHO analgesic ladder (proposed)
Nerve block
Infiltration (joint, muscular,
Trigger point,)
Epidurals
PCA
Neurolytic block
Radiofrequency/thermolesion
Spinal stimulators
Adjuvants
Steroids
Anxiolytics
Antidepressants
Hypnotics
Anticonvulsants
Antiepileptic
Gabapentinoids
(gabapentin and
pregabalin)
Membrane stabilizers
Sodium channel
blockers
NMDA receptor
antagonists for the
treatment of
neuropathic pain
Cannabinoids
Adaptation analgesic ladder
The advantage of this proposal is that one may
ascend slowly one step at a time in the case of
chronic pain and if necessary, increase the rate of
climb according to the intensity of the pain.
This adaptation can be used for acute pain in
emergency rooms and post-operative situations
and begins directly with step IV to control high
intensity pain.
The physicians can adjust and decrease the
stepped level of analgesics.
Adaptation analgesic ladder
The fourth step is recommended for the treatment
of crises of chronic pain.
Interventional pain literature suggests that there is
moderate evidence for the use of transforaminal
epidural steroid injections, lumbar percutaneous
and spinal endoscopy for painful lumbar
radiculopathy and limited evidence for intradiscal
treatments in low back pain.
Step up, step down
This version of the analgesic ladder can be used in a
bidirectional fashion: the slower upward pathway for chronic
pain and cancer pain, and the faster downward direction for
intense acute pain, uncontrolled chronic pain, and
breakthrough pain.
The advantage of this proposal is that one can ascend slowly
one step at a time in the case of chronic pain and, if
necessary, increase the rate of climb according to the
intensity of the pain.
However, one can start directly at the fourth step, in extreme
cases, to control pain of high intensity, using patientcontrolled analgesia pumps for continuous intravenous,
epidural, or subdural administration.
STEP IV
Neurosurgical
Procedures
Acute pain
STEP III
Chronic pain without control
Acute crises of chronic pain
STEP II
STEP I
Nerve block
Epidurals
PCA
Neurolytic block therapy
Spinal stimulators
Weak opioids
Non opioid
Analgesics
NSAID
Strong Opioids
Methadone
Oral administration
Transdermal patch
Chronic pain
Non malignant
And Cancer pain
NSAID
+/- Adjuvants at each step
PCA (Patient Controlled Analgesia)
NSAID: Non Steroidal Anti-Inflammatory Drugs
G. Vargas-Schaffer. Is the WHO analgesic ladder still valid?: Twenty-four years of experience Can Fam Physician 2010;56:514-7
Adaptation analgesic ladder
This adaptation can be used for nociceptive pain and for
combined nociceptive and neuropathic pain.
Not for pure neuropathic pain.
In neuropathic pain the treatment algorithm is completely
different, and opioids should be considered adjuvant
medications and not the principal drugs for the treatment of
such pain.
Several guidelines for the treatment of neuropathic pain
were published in 2007, the first by the Canadian Pain
Society and the second by the International Association for
the Study of Pain, and 2008 Quebec guideline.
Quebec guideline for neuropathic Pain
1re ligne
Prgabaline
Gabapentine
2e ligne
Antidpresseurs tricycliques (ADT) ou
ttracycliques
IRSN
Anesthsique local
3e ligne
Venlafaxine
Duloxtine
ISRS
Cannabinodes
Autre antidpresseur
Dronabinol
Nabilone
THC/CBD par voie buccale
Citalopram
Paroxtine
Autre antidpresseur
Bupropion
4e ligne
Mthadone
Ktamine
Mexiltine
Baclofne
Clonidine
Clonazpam
Autres anticonvulsivants
Topiramate
Carbamazpine
Lvtiractam
Lamotrigine
dconseiller
Mpridine
Phnytone
Opiodes et tramadol
Pour les opiodes et tramadol:
Utiliser les courtes actions en 1re ligne en association avec les autres agents de 1 re ligne en prsence des situations suivantes :
- soulagement rapide pendant la titration des agents de 1 re ligne (jusqu la posologie efficace);
- pisodes dexacerbation grave de la douleur / douleur neuropathique aigu / douleur neuropathique lie au cancer.
Utiliser en 2e ligne en monothrapie ou en association (lorsquune utilisation long terme est envisage, favoriser ladministration dagents longue
dure daction).
Boulanger A et al. Lactualit mdicale 2008; 8(12)25-30.
STEP IV
Neurosurgical
Procedures
Acute pain
STEP III
Chronic pain without control
Acute crises of chronic pain
STEP II
STEP I
Nerve block
Epidurals
PCA
Neurolytic block therapy
Spinal stimulators
Weak opioids
Non opioid
Analgesics
NSAID
Strong Opioids
Methadone
Oral administration
Transdermal patch
Chronic pain
Non malignant
And Cancer pain
NSAID
+/- Adjuvants at each step
PCA (Patient Controlled Analgesia)
NSAID: Non Steroidal Anti-Inflammatory Drugs
G. Vargas-Schaffer. Is the WHO analgesic ladder still valid?: Twenty-four years of experience Can Fam Physician 2010;56:514-7
How to step down
the analgesic ladder?
Stabilize the pain intensity in acute pain for 3-4
weeks.
Stabilize the pain intensity for 3 months or more in
chronic pain.
Choose the best time with your patient.
Reduce dose 10% every 2 weeks.
Do not compromise the quality of life of your
patient.
If necessary use complementary therapy.
How to position the patient at the
center of the pain control strategy?
STEP IV
Chronic/ Palliative
Strong Opioids
Invasive Tx.
Acupuncture
Massage, TENS,
Exercises, etc.
Physiotherapy
Ergotherapy
STEP III
Chronic/Severe Pain
STEP II
Chronic/Moderate Pain
Weak opioids
STEP I
Acute /Mild Pain
Strong Opioids
Adaptation
comfort and
Rehabilitation
Physiotherapy
Ergotherapy
Physiotherapy
Ergotherapy
Psychology/ Behavioral therapy/Psychiatry
Non opioid
Analgesics
NSAID
Physiotherapy
Ergotherapy
NSAID
+/- Adjuvants at each step
Therapeutic education programs in pain management
Vargas-Schaffer G 2012
Educating for better care
in Pain management
Therapeutic patient education
Must allow the patient to acquire and
maintain skills that help them to live
optimally with their illness.
Is a continuous process, integrated care
and patient-centered.
Includes activities, organized information,
learning and psychological support.
Continuing Education Programmes for Health Care Providers in the Field of Prevention of Chronic Diseases WHO 1998
Therapeutic patient education
Is education managed by health care
providers trained in the education of patients.
Is designed to enable a patient (or a group of
patients and families) to manage the
treatment of their condition and prevent
avoidable complications, while maintaining or
improving their quality of life.
Continuing Education Programmes for Health Care Providers in the Field of Prevention of Chronic Diseases WHO 1998
Therapeutic patient education
Is therefore designed to train patients in the skills of
self-managing or adapting treatment to their
particular chronic disease, and in coping processes
and skills.
It should also contribute to reducing the cost of longterm care to patients and to society.
It is essential to the efficient self-management and
to the quality of care of all long-term diseases or
conditions, though acutely ill patients should not be
excluded from its benefits.
Continuing Education Programmes for Health Care Providers in the Field of Prevention of Chronic Diseases WHO 1998
Educational program in pain
management
Psychology
Nursing
Physiotherapy
Patient
MD
Nutrition
Ergotherapy
Educational program in pain
management
Improves adherence.
Helps the patient understand medication responses.
Allays fears about particular treatments or medications.
Increases satisfaction with treatment by promoting realistic
expectations.
Strengthens the clinicianpatient relationship by
demonstrating respect and enhancing patient feelings of selfefficacy.
Improves health, well-being, and outcomes.
Continuing Education Programmes for Health Care Providers in the Field of Prevention of Chronic Diseases WHO 1998
Why patient education in pain
management?
Therapeutic decision
Interdisciplinary teamwork
Quality of life
Side effets
Functional recovery
Conclusion
The WHO analgesic ladder remains a
tremendously valuable tool for clinical
practice
This proposed modification of the WHO
analgesic ladder is not intended to negate or
advise against use of the original ladder.
Conclusion
After 26 years of use the analgesic ladder has
demonstrated its effectiveness and widespread
usefulness; however, modifications are
necessary to ensure its continued use for
knowledge transfer in pain management.
Thanks for your attention
Questions?...
Bibliography
G. Vargas-Schaffer. Is the WHO analgesic ladder still valid?: Twenty-four years of experience Can Fam
Physician 2010;56:514-7
World Health Organization. Traitement de la douleur cancreuse. Geneva,Switz: World Health
Organization; 1987.
World Health Organization. Traitement de la douleur cancreuse. Geneva, Switz: World Health
Organization; 1997.
Azevedo So Leo Ferreira K, Kimura M, Jacobsen-Teixeira M. The WHO analgesic ladder for cancer
pain control, twenty years of use. How much pain relief does one get from using it? Support Care Cancer
2006;14(11):1086-93.
Kanpolat Y. Percutaneous destructive pain procedures on the upper spinal cord and brain stem in cancer
pain: CT-guided techniques, indications and results. Adv Tech Stand Neurosurg 2007;32:147-73.
Miguel R. Interventional treatment of cancer pain: the fourth step in the world Health Organization
analgesic ladder? Cancer Control 2000;7(2):149-56.
Moulin DE, Clark AJ, Gilron I, Ware MA, Watson CP, Sessle BJ, et al. Pharmacological management of
chronic neuropathic painconsensus statement and guidelines from the Canadian Pain Society. Pain Res
Manag. 2007;12(1):13-21.
Dworkin RH, OConnor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, et al. Pharmacologic
management of neuropathic pain: evidence-based recommendations. Pain 2007;132(3):237-51. Epub
2007 Oct 24. DOI: 10.1016/j. pain.2007.08.033.
Management of pain in leukemic children using the WHO analgesic ladder.Geeta MG, Geetha P,
Ajithkumar VT, Krishnakumar P, Kumar KS, Mathews L. Indian J Pediatr; 2010 Jun;77(6):665-8.
Bibliography
The second step of the analgesic ladder and oral tramadol in the treatment of mild to moderate cancer
pain: a systematic review.Tassinari D, Drudi F, Rosati M, Tombesi P, Sartori S, Maltoni M.
Palliat Med; 2011 Jul;25(5):410-23.
Are the drug prescription quality indicators of the World Health Organization still valid?].
Frhlich SE, Mengue SS. Cien Saude Colet; 2011 Apr;16(4):2289-96.
From ladder to platform: a new concept for pain management. Leung L. J Prim Health Care;
2012;4(3):254-8.
Choice of opioids and the WHO Ladder. Glare P. J Pediatr Hematol Oncol; 2011 Apr;33 Suppl 1:S6-S11.
Continuing Education Programmes for Health Care Providers in the Field of Prevention of Chronic
Diseases WHO 1998
P.-Y. Traynard, R. Gagnayre Qu'est-ce que l'ducation thrapeutique, ducation thrapeutique, Masson
2007 .
M. Balcou-Debussche. L'ducation des malades chroniques : une approche ethno-sociologique,
Paris:Editions des Archives Contemporaines;2006,280 p.
D. Bruttomesso, R. Gagnayre, D. Leclercq, D. Crazzolara D, E. Butasata, J.F. dIvernois, E. Casiglia, A.
Tiengo, A. Baritussio. "The use of degrees of certainty to evaluate knowledge" IN : Patient education and
counseling, 2003, Vol. 51, n1, p. 29-37
HAS-INPES Structuration dun programme dducation thrapeutique du patient dans le champ des
maladies chroniques Juin 2007.
