A) ANALGESIC LADDER :

● The World Health Organization (WHO) analgesic ladder forms the basis of many
approaches to the use of analgesic drugs.
● There are essentially three steps: non-opioid analgesics, weak opioids and strong
opioids. The analgesic efficacy of non-opioids, such as paracetamol and non-steroidal
anti-inflammatory drugs (NSAIDs) (e.g. aspirin, ibuprofen and diclofenac), is limited
by side effects and ceiling effects, that is, beyond a certain dose, no further
pharmacological effect is seen
● If pain remains uncontrolled, then a weak opioid, such as codeine or dihydrocodeine,
may be helpful. There may be additional benefit in combining a weak opioid with a
non-opioid drug, although many commercial preparations contain inadequate
quantities of both components and are no more effective than a non-opioid alone.
● Strong opioids, of which morphine is considered the gold standard, have no ceiling
effect and therefore increased dosage continues to give increased analgesia but side
effects often limit effectiveness. Adjuvant drugs, such as corticosteroids,
antidepressants or anti-epileptics, may be considered at any step of the ladder.

B) Algorithm of management of acute pain

C) ALGORITHM FOR MANAGEMENT OC CHRONIC MALIGNANT PAIN/ CANCER PAIN :
Specific cancer pain syndromes
Types of cancer pain
Cancer of the pancreas
Mesothelioma of the lung
Metastatic bone pain
Management of pain
● Surgery, radiotherapy and chemotherapy may
relieve pain for long periods, as does neurolytic
blockade of the coeliac plexus
● Opioid analgesics 529 Pain 33 are useful and may
be administered intravenously or epidurally by
either bolus injection or continuous infusion
● The WHO analgesic ladder should be used first,
but it should be remembered that a NSAID may be
beneficial as inflammation is often a component of
the chest wall involvement
● Adjuvants such as TCAs or steroids may be helpful
● As the tumour progresses, nerve blocks or
neurosurgery may be necessary, and invasion of
the vertebrae can lead to nerve root or spinal cord
compression. In the latter case, high dose steroids
such as dexamethasone may be given
intravenously, but radiotherapy is also useful in
reducing the size of the tumour.
● Metastatic bone pain is usually treated with
courses of chemotherapy and radiotherapy, but
analgesics may also be beneficia
● A prostaglandin like substance has been isolated
from bone metastases and therefore NSAIDs and,
more recently, bisphosphonates are often used in
bone pain.
● Steroids also interfere with prostaglandin
formation and dexamethasone, therefore, has a
role, especially where there is nerve root or spinal
cord compression