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The WHO Analgesic Step Ladder

The WHO Analgesic Step Ladder. Strong opioid +/- NSAID +/- adjuvant. If pain is unrelieved on lower step, then progress up the ladder. STEP 3. Severe pain. Weak opioid+/- NSAID +/- adjuvant. Moderate pain. STEP 2. Paracetamol +/- NSAID +/- adjuvant. Mild-mod pain. STEP 1. Scenario.

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The WHO Analgesic Step Ladder

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  1. The WHO Analgesic Step Ladder Strong opioid +/- NSAID +/- adjuvant If pain is unrelieved on lower step, then progress up the ladder STEP 3 Severe pain Weak opioid+/- NSAID +/- adjuvant Moderate pain STEP 2 Paracetamol +/- NSAID +/- adjuvant Mild-mod pain STEP 1

  2. Scenario A 38 year old woman with known glioblastoma stage 4 Recently underwent radiotherapy and is on a reducing course of dexamethasone She comes to see you with headaches What do you want to know?

  3. She has tried paracetamol up to 4 x daily What do you want to know? It is of no help What do you do?

  4. She is given cocodamol 8/500 2 qds No help She is tried on codydramol 2 tabs qds No help She then is given dihydrocodeine 30-60mg qds No help She is tried on solpadol 2 tabs qds No help She then tries tylex 2 tabs qds No help What next?

  5. If someone needs an opioid what is the best one to start with? What is a suitable starting dose?

  6. QUIZ: What is the usual starting dose of oramorph? Will she definitely take it? If not-why not? Any thing you should routinely advise on, or even co-prescribe?

  7. You give her some oramorph to supplement her regular cocodamol 30/500 2 tabs qds. When do you plan to revisit symptom control? How? Next week you find that: she has taken 10mg oramorph 4 x in the last 24 hours What do you want to know? What next? What do you prescribe/try for the next 24 hours? QUIZ ctd

  8. Now she is on MST 30mg bd. What just in case dose of oramorph should she be on?

  9. QUIZ: Now she is on MST 300mg bd. What just in case dose of oramorph should she be on? How did she get from 30mg bd to 300mg bd?

  10. QUIZ ctd You have a patient who is clearly dying. He is unable to manage oral medicine but in fact was on no analgesia. He is uncomfortable Where do you start? What if he had been comfortable? What if he had been on 30mg MST bd?

  11. Write a prescription for the pain killer you want supplied (he was on MST 30mg bd prior to being unable to manage oral medication). • Write an authorisation so that a nurse can give him analgesia.

  12. What other medicines would it be sensible to supply? • For what symptoms?

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