The WHO analgesic ladder

The analgesic ladder remains the mainstay of our approach to analgesia, though this was never designed for use in isolation. Surgery, radiotherapy, and appropriate tumoricidal treatments will have an important role in some patients, as will non-drug treatments. A combined approach can lead to optimum analgesia with minimum side effects.

Analgesic drugs do, however, remain key in managing cancer pain. The choice of drug should be based on the severity of the pain, not the stage of disease. Drugs should be administered in standard doses at regular intervals in a stepwise fashion. If a non-opioid or, in turn, an opioid for moderate pain is not sufficient, an opioid for severe pain should be used.

When a non-opioid drug is used with an opioid for moderate pain, many patients find combination formulations more convenient to use. Care must be taken with the dose of each drug in the formulation; some combinations of codeine or dihydrocodeine with aspirin or paracetamol (including co-codamol and co-dydramol) contain subtherapeutic doses of the opioid. The decision to use an opioid for severe pain should be based on severity of pain and not on prognosis.

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