Fig. 5. WHO guidelines for pain therapy

Strong opioids

by injecton,

local anaesthesia

Opioids by mouth

(as pain decreases)

Aspirin and


Fig. 6. WFSA analgesic ladder

Fig. 6. WFSA analgesic ladder should be the prime consideration in analgesic selection, the approach advocates three basic steps:

Step 1

Patients with mild to moderate post-operative-related pain should be treated with a non-opioid analgesic, which should becombined with an adjuvant drug if a specific indication exists. For example, a patient with mild to moderate arm pain caused by fracture may benefit when a tricyclic antidepressant is added to acetaminophen.

Step 2

Patients who are relatively opioid naive and present with moderate to severe pain, or who fail to achieve adequate relief after a trial of a non-opioid analgesic, should be treated with an opioid conventionally used to treat pain of this intensity. This treatment is typically accomplished by using a combination product containing a non-opioid (e.g. aspirin or acetaminophen) and an opioid (such as codeine, oxycodone or propoxyphene). This drug can also be co-administered with an adjuvant analgesic.

Step 3

Patients who present with severe pain or fail to achieve adequate relief following appropriate administration of drugs on the second rung of the 'analgesic ladder' should receive an opioid agonist conventionally used for pain of this intensity. This drug may also be combined with a non-opioid analgesic or an adjuvant drug. Recently, the evidence of the long-term efficacy of this approach has been the subject of criticism. Nonetheless, the approach remains widely used and has been strongly endorsed.

Based on clinical convention, analgesic drugs can be divided into three groups:

1. the non-opioid analgesics

2. the opioid analgesics

3. the adjuvant analgesics (which are drugs with other primary indications that can be effective analgesics in specific circumstances).

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