Climbing the Pain Ladder: Understanding Pain Medications

Managing chronic pain can be a confusing proposition for patient and physician alike. Because many medications are now available to treat chronic pain, it is usually a bewildering prospect for them to find out the most beneficial one. Some patients believe that jumping right to opioid medications is the best way to treat pain, and some would not ever take opioids no matter how intense their pain become. For doctors, a system was needed to fully wring the most pain relief from available analgesics.

picture of back and neck pain

To address this problem, the World Health Organization developed the pain ladder. This is a systematic approach to pain medications, their administration, and pain relief. It involves slowly increasing the amount of medications used, and it ends with the strongest opioids available. By working a patient up the pain ladder, doctors and patients can find the best cocktail that controls pain with the least amount of opioids used.

Learn about What are Analgesics.

Non-Opioid Analgesics

Non-opioid analgesics are generally the medications found over the counter. For instance, the non-steroidal anti-inflammatory drugs (NSAIDs), such as Advil and Aleve, should be used first when attempting to address a patient’s pain. Prescription strength alternatives to these over the counter NSAIDs, such as high dose ibuprofen, are also an important first step in the pain ladder. Some patients have great pain relief with these medications, but some experience no effect.

Strong NSAIDs are also available by prescription, such as Celebrex and Voltaren, and are also part of this rung of the ladder. They can sometimes treat pain when others do not. Aspirin and acetaminophen should not be ignored, either, as they can help some patients with mild pain.

Learn more about Non-steroidal anti-inflammatory drugs (NSAIDs).

Adjuvant Analgesics

Adjuvant analgesics are the newest members of the pain ladder family. These are medications that are traditionally used for other conditions, specifically depression and seizures. Although the usage of these medications for pain is a new concept, researchers have been testing their efficacy as analgesics for a long time. For instance, the tricyclic antidepressants, such as amitriptyline, have been researched for decades for their usage against chronic pain.

Newer depression medications are also used for pain relief. In fact, Cymbalta is the first drug approved by the FDA for the treatment of chronic pain. Anti-seizure medications are helpful, particularly for nerve related pain. Gabapentin’s ability to treat peripheral neuropathy has been well documented, but recent drugs in this category, such as Lyrica, are even more effective as treatments. When these drugs are combined with a non-opioid analgesic, it can often control the manifestation of chronic pain.

Weak Opioids

Weak opioids are medications that have a small amount of narcotic medication in them, but they are usually combined pharmacologically with a non-opioid analgesic. Medications in this subset include codeine, Darvocet, dihydrocodeine, and Tramadol. These medications are generally prescribed for mild pain, but when they are combined with the non-opioid and adjuvant analgesics, they often completely relieve pain.

The weaker opioids have less risk of side effects, such as nausea, constipation, and sedation. They also have less risk of dependency, and this makes them attractive as treatment for chronic conditions. It is the combined effect of this medication with the previous two categories that forms a cocktail that is quite effective against moderate to severe pain.

Strong Opioids

Strong opioids are used when the previous medications fail to control pain. These medications include morphine, hydrocodone, oxycodone, and fentanyl, among many others. When prescribing these medications, the weaker opioid is replaced with the stronger one, and the non-opioid and adjuvant remain in place. This allows for the prescriber to use the least amount of the strong opioid as possible.

Of course, the usage of strong opioids has side effects. Many patients report feeling nausea, and the sedation is often severe. In addition, constipation is an important concern, because high dose opioids can slow down the gastrointestinal tract. This usually is addressed with stool softeners and laxatives. The possibility of dependency is greater with these medications, although it is less likely when they are taken as prescribed.

Climbing the Ladder

The pain ladder is used in a systematic fashion to achieve the best possible pain relief with the least powerful drugs. All pain patients are initially started with non-opioids. In fact, they may be self-medicating with them over the counter, but prescription strength NSAIDs should still be attempted for efficacy. If they do not work, then an adjuvant is added. Many adjuvants are specific to nerve pain, and they may not be helpful for other conditions. In addition, some adjuvants carry serious side effects, so they must be used with caution.

The next step is to add a weak opiate to the current cocktail. Some researchers question the usefulness of this step because many weak opiates are ineffective and carry the risk of certain toxicities. However, their low risk of dependency makes them a viable alternative before stronger opiates are used. The final step is to use strong opiates, starting out with very small doses. The dosage is then increased until the pain is controlled or the side effects are intolerable. This medication is generally used alongside the adjuvant and non-opioid to attack the pain from as many angles as possible.

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