1. Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi Medical college and research institute, puducherry, India

2. Ladder in analgesia

3. In 1986 WHO has developed a three-step "ladder" for cancer pain relief. nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs – “adjuvants” – should be used. USE “by the clock”, -- every 3-6 hours, rather than “on demand”

4. This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.

5. Step 1 paracetamol or aspirin or one of the nonsteroidal anti- inflammatory drugs (NSAIDs) Adjuvants Antiemetics, laxatives, antidiarrheal agents, antidepressants, antipsychotics, anticonvulsants, corticosteroids, anxiolytics and psychostimulants Biphosphonates, lidocaine patch

6. NSAIDs Especially useful in bone metastases Soft tissue and muscle infiltrates Prostaglandins more important

7. Step 2 Weak opioid + aspirin + adjuvants Some weak opioids codeine, propoxyphene, tramadol, low dose oxycodone,

8. Step 3 aspirin + adjuvants + strong opioids Morphine and hydromorphone, fentanyl and methadone as opioids 85 – 90 % go in this fashion to get adequate relief

9. Dosage schedule ?? Dose of drugs Dose that relieves pain, patient smiles

10. NSAIDs Aspirin – 500 mg every 6 hours Paracetomol 650 mg every 4- 6 hours Ibuprofen 400 mg every 6 hours Indomethacin 25 mg every 6 hours

11. Weak opiods Tramadol 50 to 100 mg 6 – 8 hrly Codeine ; 200 mg 8 hrly Propoxyphene 60 – 100 mg 8 hrly

12. Strong opioids Morphine : 30 -60 mg Methadone : 4 mg Oxycodone : 20 -30 mg p.o Pethidine 300 mg Only oral !!

14. Routes IV, IM,SC Trans dermal patch Trans rectal Trans buccal Intranasal Invasive --- intathecal, epidural

15. When it comes to pain relief -- What are not the side effects of opioids Respiratory depression Nausea, vomiting Sedation

16. Pros and cons of ladder Steps are easy Mild VAS 1 - 3 Moderate VAS 4 - 6 Severe VAS 7 - 9

17. Usefulness of step 2 ?? Why weak opioid ?? Individual basis is important pain severity, previous opioid exposure, age of the patient, extent of the cancer, and concurrent disease. Morphine 5 to 1000 mg !!

18. Opioid rotation More effects Less side effects Oral is ideal

19. Jump to step 3 Cancer pain does not always progress in the stepwise fashion that the WHO ladder implies Direct on first presentation VAS is 9 Pain crisis !!

20. No mention about nondrug control Various psychological approaches, counselling Not in step ladder

21. Should the ladder include interventional therapies as a 4th step? No

22. Pros and cons Access to opioids is mandatory so physicians can first gain experience in their use Only 85 % success The WHO method can be summarized in five phrases: "by mouth", "by the clock", "by the ladder", "for the individual" and "attention to detail."

23. Thank you all We should know that 3 step ladder is for pain relief Especially as OPD basis This has more reference to life quality change