How To Use Pain Medicines – The Analgesic Ladder

Pain- where does it originate from and how should it be treated? Here we look at the analgesic ladder to understand the different types of pain meds and when to use what.

The experience of pain is difficult to deal with for all of us. It’s especially difficult when we are caring for someone we love who is experiencing it. The causes of pain are multifactorial and the experience is unique for each individual. When we are trying to relieve pain we need to think of it in a holistic way. We need to think about the origins of pain to use the right combination of pain treatments.

period pain

The origins of pain

Nociceptive pain:

This arises from pain receptors in our body in response to a pain stimulus. Our nerves transmit this stimulus to our brain.

Neuropathic pain:

Pain that is caused by damage to part of our nervous system. Damage to nerves causes burning and shooting sensations.

Psychogenic pain:

Pain that is arising from psychological or psychiatric stress. This is real pain and causes significant distress.

These types of pain often overlap and people often experience a combination of these causes.

Pain-relieving medicines include paracetamol, NSAIDs (non-steroidal anti-inflammatory agents) and opioids. A combination of these pain-relieving medicines can be used in cases of severe chronic pain.

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Pain nerves

Pain sensations are transmitted by nerves.

Paracetamol

How does it work?

Paracetamol works by inhibiting an enzyme in the central nervous system (CNS). By inhibiting this enzyme in the CNS, it provides analgesic (pain relieving) and antipyretic (anti-fever) effects.

Safe Dosage and Regimen

For younger children, the safe regimen of Paracetamol is in the form of syrup. For adults, it is given in the form of tablets.

Adult dosing of paracetamol

The recommended paracetamol dosing for adults and children 12 years and over is 500 to 1000mg every four to six hours as necessary, with a maximum of 4000mg in any 24 hour period.

Child dosing of paracetamol

Labels on liquid paracetamol products contain clear dosing instructions. The optimal dosing for children (1 month to 12 years) is 15 mg per kg, which can be given every four to six hours as required, with no more than four doses in 24 hours.

Side Effects and Risks

Paracetamol is generally well tolerated. When used as directed it is very safe. It is extremely important to follow the instructions on the medicine label and never to exceed the maximum dose of a paracetamol in a day. In overdose, paracetamol is very dangerous and can cause life threatening liver damage.

NSAIDs

How do they work?

NSAIDs (non-steroidal anti-inflammatory medications) such as diclofenac and naproxen work by inhibiting the activity of an enzyme in all parts of the body. This stops the production of substances that cause pain and fever.

Some commonly used NSAIDs include:

  • aspirin (such as Disprin)
  • ibuprofen (such as Nurofen)
  • naproxen (such as Naprosyn)
  • diclofenac (such as Voltaren)
  • celecoxib (such as Celebrex).

Difference of traditional NSAIDs from Selective COX-2 Inhibitors

The COX-2 Inhibitors such as celecoxib and meloxicam are newer age NSAIDS.  They have much less gastrointestinal irritation than traditional NSAIDS.

Dosage

The recommended dosage of NSAIDs for analgesia is dependent on the specific product. It’s important to talk to your pharmacist about a safe dosage regime in combination with your other medications.

Side effects

Common side effects of NSAIDs include:

  • raised liver enzymes (detected by a blood test)
  • diarrhoea
  • headache
  • dizziness
  • salt and fluid retention
  • high blood pressure.

Risks

Long term,  NSAIDs increase the risk of bleeding, liver and kidney failure.

Do not take your NSAID for longer than your doctor recommends. Stop taking your NSAID and seek advice from your doctor immediately if you develop:

  • swollen ankles
  • difficulty breathing
  • black stools
  • dark, coffee-coloured vomit.

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Opioids

Opioids are morphine like drugs that encompass both naturally occurring opiates (for example morphine and codeine) derived from the resin of the opium poppy, semi-synthetic (for example oxycodone) and synthetic opioids (for example fentanyl).

How do they work?

Opioids work by decreasing the perception of pain by blocking the release of a pain neurotransmitter.

Side Effects and Risk Factors

The side effects of opioids include drowsiness, nausea, vomiting, constipation, and slowed breathing.

Opioids can be highly effective for the treatment of pain, although there is a high-risk of adverse effects and potential for dependence (addiction)

They should only ever be used in a comprehensive management plan under the guidance of your doctor.

 

Neuropathic pain

Neuropathic pain is relatively common and often poorly treated.

Management options include tricyclic antidepressants or serotonin and noradrenaline reuptake inhibitors in the first instance, followed by pregabalin or gabapentin.

Analgesic Ladder

The World Health Organisation (WHO) analgesic ladder is widely accepted for the management of nociceptive pain.

Mild Pain: Paracetamol +/- NSAIDs

Moderate Pain: Paracetamol, NSAIDs and weak opioids

Severe Pain: Paracetamol, NSAIDS and strong opioids

The combination of different drugs gives a more effective pain-killer effect because different classes of analgesics have different mechanisms of action.

Pain analgesic ladder

The Analgesic Ladder under a doctor’s management plan

Key Takeaways

Pain is a common human experience. It has many causes and needs to be treated with a holistic approach including the right pain medicine combination as well as psychological and physical therapies. Your GP will develop a comprehensive management plan that coordinates the right treatment advice. Understand your medicines and ask your doctor and pharmacist any questions you might have.

References

1: Jóźwiak-Bebenista, M., & Nowak, J. Z. (2014). Paracetamol: mechanism of action, applications and safety concern. Acta poloniae pharmaceutica71(1), 11–23.

2: Wongrakpanich, S., Wongrakpanich, A., Melhado, K., & Rangaswami, J. (2018). A Comprehensive Review of Non-Steroidal Anti-Inflammatory Drug Use in The Elderly. Aging and disease9(1), 143–150. https://doi.org/10.14336/AD.2017.0306

3: Ripamonti C. I. (2012). Pain management. Annals of oncology : official journal of the European Society for Medical Oncology23 Suppl 10, x294–x301. https://doi.org/10.1093/annonc/mds360

4: Anekar, A. A., & Cascella, M. (2021). WHO Analgesic Ladder. In StatPearls. StatPearls Publishing.

  • Dr Ganesh Naidoo
  • About the Author

    Dr Ganesh Naidoo BSc(biomed), MBBS, FRACGP is an Australian General Practitioner. He has significant clinical experience in multiple regions of Australia and has a passion for health transformation to improve clinical outcomes for all patients.

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