A stepped approach to pain prescribing

• The analgesic ladder: History

In 1986 the World Health Organization proposed a step-wise approach to use of medication in cancer related pain. The underlying principle was that medications should be used in an incremental fashion according to the patient’s reported pain intensity ie, for mild pain non-opioid medication should be prescribed, with weak opioids for moderate pain and strong opioids for severe pain. The ‘ladder’ approach encouraged use of adjunctive medicines at each rung of the ladder and use of strong opioids only at the top of the ladder. The analgesic ladder was validated as a tool for improving the treatment of cancer pain.

• Why the analgesic ladder is unhelpful for persistent pain

Unlike acute pain and cancer pain at the end of life, persistent pain not associated with cancer has an unpredictable course and may continue for many years: substantial reduction in pain intensity is rarely an achievable goal. Additionally, persistent pain may be generated by a number of different pathophysiologic mechanisms that may require different approaches to treatment. In particular, reported intensity of pain relates poorly to the degree of tissue injury and is heavily influenced by a number of factors including thoughts, emotions, understanding of the meaning of pain, previous experience of pain and the patient’s current distress. The contributors to the patient’s current experience of pain need to be explored and will influence the pain management plan.

• A stepped approach

When making medication choices to support patients with persistent pain, it may be rational to use a stepped approach but this should not be determined by reported pain intensity (which is the underlying principle of the analgesic ladder). Medications are usually a small part of the pain management plan and should be used in conjunction with non-pharmacological interventions such as advice regarding activity, physiotherapy and an explanation that pain may be resistant to medication and complete relief of symptoms is not a goal of therapy. Regardless of pain intensity, it is rational to start with non-opioid drugs, where these have some demonstrated efficacy for the condition being treated. Trials of both weak and strong opioid therapy may be considered for some patients with well-defined pain diagnoses in whom symptoms persist despite first line interventions. All drugs prescribed for pain should be subject to regular review to evaluate continued efficacy, and periodic dose tapering is necessary to evaluate on-going need for treatment.

Further Reading

• Ballantyne JC, Kalso E, Stannard C. WHO analgesic ladder: a good concept gone astray. British Medical Journal 2016; 352: i20.