Riley, J., Ross, J. R., Gretton, S. K., A'Hern, R., Du Bois, R., Welsh, K., Thick, M. (2007) Proposed 5-step World Health Organization analgesic and side effect ladder. EUROPEAN JOURNAL OF PAIN (Supple). pp. 23-30. ISSN 1090-3801

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Abstract

The WHO analgesic ladder has, up to now, been the "gold standard" for pain management. The ladder focuses on the presence or absence of pain relief but, at present, does not take into account the intolerable side effects of opioids. We believe that debilitating side effects are an equally valid reason for changing analgesia, particularly in light of new evidence supporting 'opioid switching'. Opioid switching involves changing a patient's strong opioid to an alternative strong opioid with the aim of improving analgesic response and/or reducing adverse side effects. We propose adding two additional steps to the WHO analgesic ladder to build an alternative five step ladder. The proposed fourth step involves 'opioid switching' and includes both pain and side effects as criteria for switching analgesics. The evidence for Step IV uses an algorithm derived from analysis of intervention patterns based on our recent trial data to identify the point at which a change in management is indicated. In our prospective study we identified four main factors which predict the need to switch. Three out of the four factors are opioid-induced side effects. Thus, once a strong opioid has been commenced (Step 3) and a patient has had an adequate trial of titration on their first-fine strong opioid, the need for opioid switching (Step 4) is identified in the clinical setting once side effect scores fall within a critical range, triggering a change of treatment. If switching opioids fails, we propose that the fifth and final step of the WHO analgesic ladder should involve anaesthetic intervention. (C) 2007 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved.

Item Type:	Article
Authors (ICR Faculty only):	Ahern, Roger
All Authors:	Riley, J., Ross, J. R., Gretton, S. K., A'Hern, R., Du Bois, R., Welsh, K., Thick, M.
Uncontrolled Keywords:	opioids; WHO analgesic ladder; opioid switching; anaesthetic intervention CONTROLLED-RELEASE OXYCODONE; QUALITY-OF-LIFE; CANCER PAIN; ORAL MORPHINE; TRANSDERMAL FENTANYL; MANAGEMENT; PHARMACOTHERAPY; STRATEGIES; EFFICACY; OPIOIDS
Research teams:	Clinical Units > Department of Palliative Medicine & Pain
Depositing User:	Users 10 not found.
Date Deposited:	09 Jun 2008 11:18
Last Modified:	10 Feb 2010 11:50
URI:	http://publications.icr.ac.uk/id/eprint/6338

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