Abstract
The WHO analgesic ladder has, up to now, been the “gold standard” for pain management. The ladder focuses on the presence or absence of pain relief but, at present, does not take into account the intolerable side effects of opioids. We believe that debilitating side effects are an equally valid reason for changing analgesia, particularly in light of new evidence supporting 'opioid switching'. Opioid switching involves changing a patient's strong opioid to an alternative strong opioid with the aim of improving analgesic response and/or reducing adverse side effects. We propose adding two additional steps to the WHO analgesic ladder to build an alternative five step ladder. The proposed fourth step involves 'opioid switching' and includes both pain and side effects as criteria for switching analgesics. The evidence for Step IV uses an algorithm derived from analysis of intervention patterns based on our recent trial data to identify the point at which a change in management is indicated. In our prospective study we identified four main factors which predict the need to switch. Three out of the four factors are opioid-induced side effects. Thus, once a strong opioid has been commenced (Step 3) and a patient has had an adequate trial of titration on their first-line strong opioid, the need for opioid switching (Step 4) is identified in the clinical setting once side effect scores fall within a critical range, triggering a change of treatment. If switching opioids fails, we propose that the fifth and final step of the WHO analgesic ladder should involve anaesthetic intervention.
Published Version
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