SouthWestRegionalWoundCareToolkit

B.5.3WHOPainLadderwithPainManagementGuidelines

TheWHOPainLadderiwasdevelopedin1986asaconceptualmodeltoguidethemanagementofcancerpain.There
isnowaworldwideconsensuspromotingitsuseforthemedicalmanagementofallpainassociatedwithseriousillness,
includingpainfromwounds.

Severe Pain
7 - 10 / 10

Red Flags
Unrelieved pain should raise a red
flag that attracts the attention of
the interdisciplinary team.

Painpersistingor
increasing

Moderate Pain
4 6 / 10

Step3:
Startstrongoralopioidaroundtheclockii
Morphine510mgq4htitratetopain
Dilaudid14mgq4htitratetopain
MSContinorotherlongacting3060mgq812h
Fentanyl25g/hourplusMorphineSulphate5mg.q2
hoursforbreakthrough*nevertobeadministeredto
opioidnaiveclients
+Adjuvants*
Notes:Useshortactingpreparationofsamemedication
forbreakthroughpain.Considerlowerdoseinopioidnave
andelderlypatients

Step2:
AddOpioidforModeratePainaroundtheclock2
Acetaminophen325mg+codeine30mgq4h(Tylenol#3)or
Acetaminophen325mg+codeine60mgq4h(Tylenol#4)or
Acetaminophen325/500mg+oxycodone5mgq4h(Percocet/Roxicet)
+Adjuvants*
Note:Considerstrongeropioidifpainnotcontrolledbythese
combinationsatatotaldailydoseif400mg/dayofcodeineor80mg/dayof
oxycodone

Painpersistingor
Mild Pain
increasing
1 3 / 10
Step1:
Nonnarcoticaroundtheclock2
Acetaminophen650mgq4hor

ASA650mgq4hor
Ibuprofen400mgq4hor
otherNSAIDs
+Adjuvants*
*Adjuvanttherapymedicationsthatcanhelptoenhancetheeffectsofnonopioidandopioidanalgesics
1)NSAIDs(nonsteroidalantiinflammatories)canbeusedascoanalgesicsandareusefulinreducinginflammation
2)TricyclicantidepressantsNortriptyline,Desipramine,andAmitriptylineareoptions,althoughAmitriptylinecancauseconfusion
intheelderly.Studieshaveconfirmedtheireffectivenessintreatingdiabeticneuropathyandneuropathicpainfromothersources
3)AnticonvulsantmedicationsGabapentin,Pregabalin,andCarbamazepinecanrelievetheshooting,electricalpainsofperipheral
nervedysfunction.iii
i

WorldHealthOrganization,(2009).WHOsPainReliefLadder.www.who.int/cancer/palliative/painladder/en/
Roden,A.&Sturman,E.(2009).Assessment&Managementofpatientswithwoundrelatedpain.NursingStandard,23(45)5362
3
Principlesofbestpractice:Minimizingpainatwounddressingrelatedprocedures.Aconsensusdocument.(2007).Toronto,Ontario,Canada:cWoundPediaInc.
2007.
2

SWRWCToolkit_B.5.3WHOPainLadderwithPainManagementGuidelines_Jan7_2011AdaptedfromaCarePartners/ETNOWformwith
permission2010.Appropriatecreditorcitationmustappearonallcopiedmaterials.