The document discusses pain management and the WHO pain ladder. It provides information on assessing pain, pharmacological and non-pharmacological treatment options, and guidelines for treating pain based on severity. The WHO pain ladder recommends treating mild pain with non-opioids, moderate pain with weak opioids, and severe pain with strong opioids, while also considering adjuvant therapies and non-drug measures. The goal of pain management is comprehensive, patient-centered relief using a combination of treatments tailored to each individual.

1. 1
Dr. Zulcaif Ahmad
Pharm-D, MPhil Pharmaceutics
(Scholar)

2. Contents
 Introduction
 Types
 Pain Assessment
 Medication Task
 Conclusion
 References
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3. Introduction
 What is pain & Pain Ladder?
 Highly unpleasant physical sensation caused by illness or injury.
 Pain Ladder:
 Pain ladder was created by the WHO as a guideline for the use of drugs in the
management of pain. Originally published in 1986 for the management of
cancer pain, it is now widely used by medical professionals for the
management of all types of pain.
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4. Dr. Zulcaif Ahmad 4
 PAIN HISTORY
 Description: severity, quality, location, temporal features, frequency
 Previous history
 Context: social, cultural, emotional, spiritual factors
 Interventions: what has been tried?

5. TYPES OF PAIN
NEUROPATHICNOCICEPTIVE
Somatic
• bones, joints
• connective tissues
• muscles
Visceral
• Organs –
heart, liver,
pancreas, gut,
etc.
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6. Somatic Pain
• Aching, often constant
• May be dull or sharp
• Often worse with movement
• Well localized
Eg/
– Bone & soft tissue
– Chest wall
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7. Visceral Pain
• Constant or crampy
• Aching
• Poorly localized
• Referred
Eg/
– CA pancreas
– Liver capsule distension
– Bowel obstruction
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8. COMPONENT DESCRIPTORS EXAMPLES
Steady, Dysesthetic • Burning, Tingling
• Constant, Aching
• Squeezing, Itching
• Diabetic neuropathy
• Post-herpetic
neuropathy
Paroxysmal,
Neuralgic
• Stabbing
• Shock-like, electric
• Shooting
• Lancinating
• trigeminal neuralgia
• may be a component of
any neuropathic pain
FEATURES OF NEUROPATHIC PAIN
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9. Pain Assessment
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10. “Describing pain only in terms of its
intensity is like describing music only
in terms of its loudness”
von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162
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11. Example Of A Numbered Scale
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12. Examples of Pain Scales
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15. • Dose
• Route
• Frequency
• Duration
• Efficacy
• Adverse effects
Medication Taken
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16. Pain Treatment
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17. Overview of Pain Management Standards
Patient knows best; only the patient can describe characteristics
and rate the severity of his or her pain!
Pharmacological therapies
Uses non-pharmacological therapies whenever appropriate
Provide education and counseling
Use adjuvants for specific pain (ex. bone, neuropathic)
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18. Non-Pharmacological Pain Management
 Acupuncture
 Cognitive/behavioral therapy
 Meditation/relaxation
 TENS
 Therapeutic massage
 Others…
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19. Heat
Superficial heat: heating pad, hot shower,
hot bath
Deep heat: ultrasound
Effective for pain relief, increased muscle
flexibility
Not much evidence, but obviously effective
briefly
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20. Cold
Superficial: Ice packs
Deep: cold laser
Cold effective for pain relief and
reducing inflammation, but
contracts muscles
Unclear mechanism and efficacy of
cold laser
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21. STRETCHING!
Muscle has viscoelastic properties
Slow, deep stretch paired with deep
breathing necessary
Muscle properties change for ~10 hrs
after deep stretch
Evidence not compelling, but pain-relief
effect of stretching is very obvious
clinically
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22. Other types of Exercise
Yoga
Advanced Yoga
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23. Yoga
EXCELLENT choice for exercise maintenance
Has role in decreasing active pain issues as well.
Must start in beginner class!
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24. Advanced Yoga
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25. Tai Chi
Becoming more popular topic of
research
Have found that Tai Chi practice
decreases falls in the elderly
Somewhat similar to yoga, but more
focused on gentle fluid movement, as
opposed to deep prolonged stretch
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26. Therapeutic Massage
 Therapeutic massage is a
general term that describes
any type of massage that
helps relieve pain, reduce
stress, and work on a
specific problem such as a
frozen shoulder.
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27. TENS
 Transcutaneous electrical nerve
stimulation (TENS) is a therapy that
uses low-voltage electrical current
for pain relief. You do TENS with a
small, battery-powered machine
about the size of a pocket radio.
Usually, you connect two electrodes
(wires that conduct electrical
current) from the machine to your
skin.
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29. Acupuncture
 Acupuncture is a holistic health
technique that stems from
Traditional Chinese Medicine
practices in which trained
practitioners stimulate specific
points on the body by inserting
thin needles into the skin
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31. Meditation
Increasing base of evidence for
the pain relief effects of
meditation
Decreases stress
Improved emotional acceptance
of pain
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33. Pain Treatment Options – Pharmacologic approach
Non-opioids
 Capsaicin
 Acetaminophen
 NSAIDs
 Steroid
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34. Pain Treatment Options – Pharmacologic approach (cont)
Adjuvants
 TCA: commonly used for neuropathic pain
 Gapabentin: FDA-approved for partial seizures and postherpetic neuralgia
but is also used for a wide variety of neuropathic pain syndromes, including
postoperative pain
 Lidocaine patch: FDA-approved for postherpetic neuralgia but are used for a
wide variety of local pain syndromes
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35. NSAIDs
Side-effects
 GI
 Renal: reduce GFR
 Increase fluid retention,
HTN
 Increase risk of confusion
 Platelet dysfunction
Alternative treatments
 Consider nonacetylated
salicylates or COX-2 selective
(Diclofenac, Meloxicam),
celecoxib plus PPi
 Consider topical therapy
(Capsasin)
 Consider Naproxen or Tylenol or
topical therapy
 Consider non-pharmacologic
therapy
 Consider Acetaminophen
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36. Cate
gory
Prot
otype
Mechanism of action Characteristics of
action
Clinical uses Addicti
on
Analg
esics
Morph
ine
stimulate -R,inhibit
release of excitatory
transmitters related to
pain impulse
Relieve moderate-to-
severe acute pain from
various causes. Action
lies
in central site
acute pain and
severe pain from
various causes. For
visceral colic:
combined with
atropine.
Addictio
n
NSAI
Ds
aspir
in
Inhibition of
cyclooxygenase
(COX)，
reduce biosynthesis
of prostaglandin
Most frequently used
for mild-to-moderate
pain. action lies in
peripheral site
reducing pain of
mild to moderate
intensity (headache,
toothache,arthralgia
,etc).
Little
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37. Mechanism of action of Aspirin
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38. Mechanism of action pf Morphine
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41. Corticosteroid
Indication:
 reduce compression due to edema causing structural stretching-> visceral
pain
 Anti-inflammation; Trigger point injection (must rule out septic joint first).
 Stimulate appetite
Need to weigh benefits vs. risks
Dexamethasone produces the least amount of mineralocorticoid
effect, with the highest amount of anti-inflammatory effects
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42. Corticosteroid
Indication:
 reduce compression due to edema causing structural stretching-> visceral
pain
 Anti-inflammation; Trigger point injection (must rule out septic joint first).
 Stimulate appetite
Need to weigh benefits vs. risks
Dexamethasone produces the least amount of mineralocorticoid
effect, with the highest amount of anti-inflammatory effects
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43. Summary
Only the patient can describe characteristics
and rate the severity of his or her pain.
Always consider using non-pharmalogical approach when
appropriate.
All non-opioids medication have ceiling effects.
Do not combine multiple NSAIDs. Use alternative
treatments to minimize potential side-effects.
Consider adjuvants for specific pains such as bone pain or
neuropathic.
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44. +/- adjuvant
Non-opioid
Weak opioid
Strong opioid
By the
Clock
W.H.O. ANALGESIC LADDER
+/- adjuvant
+/- adjuvant
1
2
3
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46. STRONG OPIOIDS
• most commonly use:
– morphine
– Hydromorphone (Dilaudid ®)
– transdermal fentanyl (Duragesic®)
– oxycodone
– Methadone
• DO NOT use meperidine (Demerol) long-term
– active metabolite normeperidine  seizures
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47. Conclusion
Pain management is a comprehensive, patient-centered process including
pharmacological agent, psychosocial counseling, and non-pharmacological
treatments when appropriate.
Always start with the lowest dose, least side-effect agents and reassess
frequently with patient’s input.
Use conversion chart for IV to po, and this transition should be done as soon as
possible.
 When in doubt, always ask for help from the experts.
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48. References:
Barakzoy AS, Moss AH. Efficacy of the World Health Organization
analgesic ladder to treat pain in end-stage renal disease. J Am Soc
Nephrol. 2006;17(11):3198-3203.
Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom
Manage. 2004;28(5):497-504.
Broadbent A, Khor K, Heaney A. Palliation and chronic renal failure:
opioid and other palliative medications—dosage guidelines. Progress in
Palliative Care. 2003;11(4):183-190(8).
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49.  Johnson SJ. Opioid safety in patients with renal or hepatic dysfunction. Pain
Treatment Topics website. Available at: http://pain-topics.org/pdf/Opioids-Renal-
Hepatic-Dysfunction.pdf. Accessed Dec. 7, 2013
 Ashburn MA, Lipman AG, et al. Principles of Analgesic Use in the Treatment of
Acute Pain and Cancer Pain. American Pain Society: 5th Edition. 2003
 http://apps.who.int/iris/bitstream/10665/44540/1/9789241548120_Guidelines.pdf
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