WHO 3 step ladder

1. WHO 3 step ladder Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi Medical college and research institute , puducherry , India

2. Ladder in analgesia

3. In 1986 • WHO has developed a three-step "ladder" for cancer pain relief. • nonopioids (aspirin and paracetamol); • then, as necessary, mild opioids (codeine); • then strong opioids such as morphine, until the patient is free of pain. • To calm fears and anxiety, additional drugs – “adjuvants” – should be used.  • USE “by the clock”, -- every 3-6 hours, rather than “on demand”

4. This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. • Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.

5. Step 1 • paracetamol or aspirin or one of the nonsteroidal anti-inflammatory drugs (NSAIDs) • Adjuvants • Antiemetics, laxatives, antidiarrheal agents, • antidepressants, antipsychotics, anticonvulsants, corticosteroids, anxiolytics and psychostimulants • Biphosphonates, lidocaine patch

6. NSAIDs • Especially useful in bone metastases • Soft tissue and muscle infiltrates • Prostaglandins more important

7. Step 2 • Weak opioid + aspirin + adjuvants • Some weak opioids • codeine, • propoxyphene, • tramadol, • low dose oxycodone,

8. Step 3 • aspirin + adjuvants + strong opioids • Morphine and hydromorphone, fentanyl and methadone as opioids • 85 – 90 % go in this fashion to get adequate relief

9. Dosage schedule ?? • Dose of drugs • Dose that relieves pain , patient smiles

10. NSAIDs • Aspirin – 500 mg every 6 hours • Paracetomol 650 mg every 4- 6 hours • Ibuprofen 400 mg every 6 hours • Indomethacin 25 mg every 6 hours

11. Weak opiods • Tramadol 50 to 100 mg 6 – 8 hrly • Codeine ; 200 mg 8 hrly • Propoxyphene 60 – 100 mg 8 hrly

12. Strong opioids • Morphine : 30 -60 mg • Methadone : 4 mg • Oxycodone : 20 -30 mg p.o • Pethidine 300 mg • Only oral !!

14. Routes • IV, IM ,SC • Trans dermal patch • Trans rectal • Trans buccal • Intranasal • Invasive --- intathecal , epidural

15. When it comes to pain relief -- • What are not the side effects of opioids • Respiratory depression • Nausea , vomiting • Sedation

16. Pros and cons of ladder • Steps are easy • Mild VAS 1 - 3 • Moderate VAS 4 - 6 • Severe VAS 7 - 9

17. Usefulness of step 2 ?? • Why weak opioid ?? • Individual basis is important • pain severity, previous opioid exposure, age of the patient, extent of the cancer, and concurrent disease. • Morphine 5 to 1000 mg !!

18. Opioid rotation • More effects • Less side effects • Oral is ideal

19. Jump to step 3 • Cancer pain does not always progress in the stepwise fashion that the WHO ladder implies • Direct on first presentation VAS is 9 • Pain crisis !!

20. No mention about nondrug control • Various psychological approaches , counselling • Not in step ladder

21. Should the ladder include interventional therapies as a 4th step? • No

22. Pros and cons • Access to opioids is mandatory so physicians can first gain experience in their use • Only 85 % success • The WHO method can be summarized in five phrases: "by mouth", "by the clock", "by the ladder", "for the individual" and "attention to detail."

23. Thank you all • We should know that 3 step ladder is for pain relief • Especially as OPD basis • This has more reference to life quality change