SouthWestRegionalWoundCareToolkit

B.5.3WHOPainLadderwithPainManagementGuidelines

TheWHOPainLadderiwasdevelopedin1986asaconceptualmodeltoguidethemanagementofcancerpain.There
isnowaworldwideconsensuspromotingitsuseforthemedicalmanagementofallpainassociatedwithseriousillness,
includingpainfromwounds.

Severe Pain
Red Flags 7 - 10 / 10
Unrelieved pain should raise a red
flag that attracts the attention of Step3:
the interdisciplinary team. Startstrongoralopioidaroundtheclockii
Morphine510mgq4htitratetopain
Dilaudid14mgq4htitratetopain
MSContinorotherlongacting3060mgq812h
Fentanyl25g/hourplusMorphineSulphate5mg.q2
hoursforbreakthrough*nevertobeadministeredto
opioidnaiveclients
+Adjuvants*
Painpersistingor Notes:Useshortactingpreparationofsamemedication
increasing forbreakthroughpain.Considerlowerdoseinopioidnave
Moderate Pain andelderlypatients
4 6 / 10

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/
2
Roden,A.&Sturman,E.(2009).Assessment&Managementofpatientswithwoundrelatedpain.NursingStandard,23(45)5362
3
Principlesofbestpractice:Minimizingpainatwounddressingrelatedprocedures.Aconsensusdocument.(2007).Toronto,Ontario,Canada:cWoundPediaInc.
2007.
1
SWRWCToolkit_B.5.3WHOPainLadderwithPainManagementGuidelines_Jan7_2011AdaptedfromaCarePartners/ETNOWformwith
permission2010.Appropriatecreditorcitationmustappearonallcopiedmaterials.