SAN DIEGO — Add a half step and a new rung to bring the World Health Organization's three-step “analgesic ladder” into the 21st century, Joshua P. Prager, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.
The venerable World Health Organization (WHO) pain management guidelines, crafted about 15 years ago, described treatments for three levels of pain: mild, mild/moderate, or moderate/severe pain, he explained.
For mild pain, the WHO recommends nonopioid therapies like acetaminophen or traditional nonsteroidal anti-inflammatory drugs. Mild/moderate pain calls for an opioid (codeine, dihydrocodeine, hydrocodone, or oxycodone), often with a nonopioid. For moderate/severe pain, treat with a pure opioid in sustained-release or rescue therapy (morphine, fentanyl, oxycodone, or hydromorphone), the WHO suggests. At all levels, consider including adjuvant therapy.
One goal of these guidelines was to convince physicians in Third World countries that it's okay to give opiates for pain, said Dr. Prager, a pain specialist in Los Angeles. To make the analgesic ladder more relevant to U.S. physicians in the 21st century, he adds a half step between the mild and mild/moderate rungs to include new medications that have appeared since the guidelines were written.
These include tramadol (Ultram), gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), the lidocaine patch, and cyclooxygenase-2 (COX-2) inhibitors. Despite recent controversy around possible cardiovascular problems from long-term use of high-dose COX-2 inhibitors, Dr. Prager said those drugs have been a real boon to his practice when used in lower doses to avoid the GI toxicity associated with chronic use of traditional NSAIDs, he said.
Dr. Prager has been a speaker for the companies that make tramadol, gabapentin, pregabalin, and one of the COX-2 inhibitors. He has received research funding from the company that makes the lidocaine patch.
Beyond the moderate/severe pain level at the top of the analgesic ladder, Dr. Prager adds a fourth rung of severity and treatment that is not yet recognized by WHO recommendations. Treatments for patients in this fourth rung with intractable or refractory pain would include spinal cord stimulation, direct delivery of medications to the spinal fluid, and neuroablation.
Dr. Prager said that several other pain management guidelines are available:
▸ The American Pain Society's Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain.
▸ The American Society of Clinical Oncology's Cancer Pain Assessment and Treatment Curriculum Guidelines.
▸ The Oncology Nursing Society's Position Paper on Cancer Pain.
▸ American Society of Anesthesiologists guidelines.
Dr. Prager gives these guidelines to patients. “We find that if patients and families understand their rights to pain management, they will take a more active role.”
The WHO also provides important recommendations in its 1990 Cancer Pain Relief and Palliative Care guidelines on when to start palliative care, Dr. Prager noted; these guidelines focus on palliative care for cancer therapy, but they could be applied to any chronic disease with associated pain, including sarcoidosis, peripheral vascular disease, or multiple sclerosis.
Pain Guidelines—By the Letter
All the best advice from the various pain treatment guidelines might be condensed down to these precepts, Dr. Prager suggested:
Ask about pain regularly.
Assess pain systematically.
Believe the patient and family members in their reports of pain and what relieves it. Physicians who are not pain experts may be skeptical about this approach, he acknowledged. “I would rather make the mistake of giving a pain medication to somebody who doesn't have pain, and then figure out what's going on, than withhold pain medicine from somebody who really needs it. Of those two types of errors, I think one is much worse than the other.”
Choose pain control options appropriate for the patient, family, and setting. Take the family's beliefs into account when picking therapies and modes of delivery.
Deliver interventions in a timely, logical, and coordinated fashion. “There are a variety of ways of delivering drugs now that weren't available several years ago,” he noted.
Fentanyl citrate lozenges or “lollipops” may cost about $10 each, but they can deliver enough analgesia to avoid a more costly at-home fentanyl infusion.
Empower patients and their families.
Enable them to control their course to the greatest extent possible.