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Tools and rules for managing pain

The number one tool that doctors use when creating treatment plans for pain is the World Health Organisation's analgesic ladder. Professor of Emergency Medicine Ian Rogers explains how this tool helps doctors decide which pain medications to give patients.

4 Jan 2019

The analgesic ladder helps medical practitioners prescribe the right medication for their patient’s pain. Starting with simple medications and adding strong pain medications allows the pain medications to work together for maximum benefit with the least side effects.

The rungs on the analgesic ladder

There are four steps in all, and if you find yourself past the second step, you will need to consult a health practitioner.

At the base of the ladder, sit physical therapies such as the application of splints or slings.

The next rung is over-the-counter medication such as ibuprofen and paracetamol. Both of these are effective and helpful in saving the use of stronger medications later on. Ibuprofen is slightly more effective, as it has an anti-inflammatory effect. Both are relatively safe when taken in prescribed doses, but can be harmful when taken long term or in excessive amounts without a doctor’s review. An overdose of paracetamol is toxic to the liver and ibuprofen can cause gastrointestinal upset and worsen kidney function.

The third step is an oral opioid such as tramadol or Panadeine Forte. Oxycodone, morphine and buprenorphine are stronger opioids that are restricted to severe pain.

The last rung on the ladder is the injectable opiates such as morphine. If injectable morphine is required then you might be prescribed a patient controlled analgesic which enables you to administer levels of pain medication to suit your needs. This system gives you control over dosage, but is designed to avoid overdose.

St John of God Health Care pain management

When to start taking pain medication?

It is best to take what you need, as advised by your health practitioner, before the pain gets too bad

This is because it is much more difficult to treat pain when it’s already out of control.

How does effective pain management help avoid the risk of chronic pain?

Anaesthetist and Pain Specialist Dr Roger Tan says good post-operative pain relief, which may include opioids, is the main determinant in reducing the risk of chronic pain.

“Morphine-type medications are strong and useful for short periods of time for management of pain, for example, to continue with rehabilitation after orthopaedic surgery or acute back pain,” he says.

“It allows you to mobilise, improve your range of motion and maintain your normal function.”

What about side effects?

Dr Tan says real concerns with using opiate or morphine-type medication are the side effects such as excessive drowsiness, impact level of breathing, nausea, vomiting and constipation

“Morphine medications should also be kept to short term use to reduce the risk of addiction and dependence,” he says.

“Opioid medications should be restricted to less than one month after surgery at the very most.

“If opioid medication is still being required after three months, then careful management will be required by your doctor.”

What's next?

Recent advances in pain medication include drugs designed to specifically target nerve pain. Medication such as Pregabalin (Lyrica) has been useful in treatment of nerve pain but also severe acute pain.

Professor Ian Rogers Emergency Physician

About the Author

Professor Ian Rogers is an emergency physician at St John of God Murdoch Hospital. He also leads the hospital's research into emergency medicine.