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Early Analgesia on Arrival
Published in Kajal Jain, Nidhi Bhatia, Acute Trauma Care in Developing Countries, 2023
Following secondary triaging, patients should be divided into green, yellow and red zones, depending on the severity of their pain and managed accordingly (Figure 5.2). Subjects with extreme or acute pain must be advanced to yellow and red zones correspondingly for modification of the analgesia strategy. The selection of analgesic should be based on the main assessment score and the World Health Organization (WHO) pain ladder. The WHO pain ladder, initially developed as a conceptual model to guide the management of cancer pain, is now accepted worldwide for the medical management of pain coupled with serious illness, including traumatic pain. Multimodal analgesia is critical for provision of adequate analgesia to the acutely injured patient; however, patient haemodynamics, respiratory and mental status must all affect the choice of pharmacologic interventions (Table 5.1).
Opioid Analgesia After Discharge from Hospital
Published in Pamela E. Macintyre, Stephan A. Schug, Acute Pain Management, 2021
Pamela E. Macintyre, Stephan A. Schug
One way to explain the concept of tapering to patients and their treating doctors is to use the idea of a “reverse pain ladder” (Levy et al, 2020). This is based on the well-known pain ladder used to describe the steps taken to escalate analgesia in patients with cancer, with the highest step being opioid medications. The reverse ladder simply means these steps are taken in reverse order.
Introduction to the clinical stations
Published in Sukhpreet Singh Dubb, Core Surgical Training Interviews, 2020
I would again ensure that the patient had adequate analgesic and was being hydrated through intravenous infusion. I would progress with pain relief in a step-wise manner, along the WHO recommended pain ladder, though initially with more robust analgesic such as ketorolac alongside alpha blockage with tamsulosin. Since there are also signs of sepsis, I would initiate appropriate antibiotics to begin treating this with a combined regimen – based on blood and urinary results – such as ciprofloxacin and gentamicin. I would consult the hospital regulated policy and seniors as appropriate. Finally, I would discuss the results with the patient, and alongside a senior begin preparations for the insertion of a ureteric stent or nephrostomy to drain the kidney.
Appropriate use of tapentadol: focus on the optimal tapering strategy
Published in Current Medical Research and Opinion, 2023
Renato Vellucci, Diego Fornasari
Since its introduction several decades ago, the World Health Organization’s (WHO) 3-step pain ladder has provided useful guidance for the prescribing of pain medication based on the level of pain4. Originally developed for cancer pain, the WHO pain ladder has been widely used in non-cancer pain4; however, while opioids are considered cornerstone treatment for the management of moderate-to-severe chronic cancer pain8,9, their role in chronic non-cancer pain is controversial4. Recent advances in the understanding of pain anatomy and physiology, and the improved diversity of available therapeutic options have resulted in modification of the WHO pain ladder, particularly with respect to treating chronic non-cancer pain4. An individualized, patient-centered approach for the diagnosis and treatment of pain is essential in order to establish a therapeutic alliance between patient and clinician that will help to ensure successful outcomes10. This includes consideration of an opioid in selected patients when chronic non-cancer pain cannot be controlled with non-opioid options4.
Comparative risk-benefit profiles of weak opioids in the treatment of osteoarthritis: a network meta-analysis of randomized controlled trials
Published in Postgraduate Medicine, 2022
Wei Li, Hongyi He, Zidan Yang, Ziying Wu, Dongxing Xie
World Health Organization has announced a 3-step pain ladder for pain management: 1) the use of a non-opioid drug for mild pain; 2) the use of a weak opioid for moderate pain; and 3) the use of a strong opioid for severe pain [52]. Since the use of strong opioids is associated with the development of physical dependence and tolerance, weak opioids are still the most commonly prescribed therapy to relieve OA-related pain [6]. Codeine is a natural derivative of opium alkaloids that frequently causes constipation, to a varying degree, that may jeopardize the continuation of treatment [53]. Tramadol, is a less active prodrug characterized by a dual mode of action as a noradrenaline reuptake inhibitor and as an agonist of the μ-opioid receptor [54,55]. Our results were consistent with the literature reports suggesting that tramadol and codeine had an excellent efficacy profile but an inferior therapeutic safety than placebo. Dextropropoxyphene is considered a weak narcotic and is a third to a half as potent as codeine [56]. Our results indicated that dextropropoxyphene was a weak opioid with a better safety profile but poor efficacy. Dihydrocodeine, a semi-synthetic opioid, has established analgesic efficacy; its parenteral potency is approximately one-sixth of morphine and equipotent to codeine [57]. Dihydrocodeine has been licensed in most countries to treat moderate to severe pain, but its efficacy in OA treatment is still uncertain due to the lack of evidence for multiple-treatment comparisons [58].
Managing pain and inflammation associated with musculoskeletal disease: time for a change?
Published in Current Medical Research and Opinion, 2022
Bernd Wolfarth, Cathy Speed, Kirill Raymuev, Luc Vanden Bossche, Alberto Migliore
Acetaminophen, better known as paracetamol, is useful to treat mild-to-moderate acute/acute on chronic pain or fever but has no anti-inflammatory action. It is believed to exert its effect centrally by inhibiting COX-2 and cannabinoid receptors in the brain. Although generally regarded as safe within recommended doses, a NICE review suggests that paracetamol is of “reduced effectiveness” in osteoarthritis22,23. Higher up the pain ladder, opioids have a powerful central analgesic and sedative effect but are associated with side effects such as drowsiness and constipation24. With long-term use there is a risk of addiction, and opioids may be less effective on their own for chronic pain with or without musculoskeletal injury than non-opioid strategies25. Where neuropathic pain is a feature, anti-depressants (e.g. amitriptyline) and anti-epileptics (e.g. gabapentin, pregabalin) may be of value but are also associated with significant side effects26.