PAIN-WHO PAIN LADDER

SUMMARY

1. Step 1, mild pain, pain score 1-4: non-opioid analgesics (NSAIDs, acetaminophen, ASA).

2. Step 2, moderate pain, score 5-6: weak opioid analgesics (codeine, hydrocodone, tramadol).

3. Step 3, severe pain, score 7-10: strong opioid analgesics (morphine, oxycodone, methadone, levorphanol, fentanyl).

4. Step 4, refractory pain: advanced therapies/interventions (parenteral opioids, palliative treatments, nerve blocks, spinal analgesics, vertebroplasty, radiofrequency ablation, neuromodulation).

5. Adjuvant drugs may be added at any step: antidepressants, anticonvulsants, benzodiazepines, neuroleptics, antihistamines, corticosteroids, calcitonin, and psychostimulants. These supplement analgesia and/or manage side-effects.

6. Patients who do not respond to oral medications or have difficulty with limiting side effects may benefit from nerve blocks, TENS, or surgical intervention such as cordotomy, dorsal column stimulation implantation, or central-spinal administration of analgesics (opioid, local anesthetics, clonidine and or baclofen).

Reference(s)

Cifu, D.X. (2020). Braddom’s physical medicine and rehabilitation. Elsevier. Get it on Amazon.
Cuccurullo, S. (2019). Physical medicine and rehabilitation board review. New York: Demosmedical. Get it on Amazon.
O’Young, B., Young, M.A. and Stiens, S.A. (2008). Physical Medicine and Rehabilitation Secrets. Mosby. Get it on Amazon.