Who Analgesic Ladder
Who Analgesic Ladder
Who Analgesic Ladder
still valid?
Canada
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.
Chronic pain
Rodin 1898
Chronic pain
Rodin 1898
Declaration of Montreal
Declaration that Access to Pain Management Is
a Fundamental Human Right
TREATMENT OF PAIN
Pharmacological
Invasive treatment
Drugs
Non Pharmacological
3.
Analgesics should be prescribed according to pain intensity as evaluated by a scale of intensity of 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
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
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
STEP IV
Neurosurgical
Procedures
Acute pain
STEP III
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
G. Vargas-Schaffer. Is the WHO analgesic ladder still valid?: Twenty-four years of experience Can Fam Physician 2010;56:514-7
2e ligne
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).
STEP IV
Neurosurgical
Procedures
Acute pain
STEP III
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
G. Vargas-Schaffer. Is the WHO analgesic ladder still valid?: Twenty-four years of experience Can Fam Physician 2010;56:514-7
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
Non opioid
Analgesics
NSAID
Physiotherapy
Ergotherapy
NSAID
+/- Adjuvants at each step
Nursing
Physiotherapy
Patient
MD
Nutrition
Ergotherapy
Therapeutic decision
Interdisciplinary teamwork
Quality of life
Side effets
Functional recovery
Conclusion
The WHO analgesic ladder remains a
tremendously valuable tool for clinical
practice
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.
Questions?...
Bibliography
G. Vargas-Schaffer. Is the WHO analgesic ladder still valid?: Twenty-four years of experience Can Fam
Physician 2010;56:514-7
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