1. The WHO Analgesic Step Ladder
If pain is unrelieved on lower
step, then progress up the ladder
Strong opioid +/- NSAID +/- adjuvant
STEP 3
Severe
pain
Weak opioid+/- NSAID +/- adjuvant
The emphasis is on individualisation of pain control, with tailoring of medication to fit each patient’s requirements.
Anyone with persistent pain needs regular pain control: analgesics need to be prescribed regularly to optimise pain control and prevent pain recurring.
Usually medication by mouth is the first choice route.
Moderate pain
STEP 2
Paracetamol +/- NSAID +/- adjuvant
Mild-mod pain
STEP 1 1

2. Scenario A 38 year old woman with known glioblastoma stage 4
Recently underwent radiotherapy and is on a reducing course of dexamethasone
She comes to see you with headaches
What do you want to know?

3. She has tried paracetamol up to 4 x daily
What do you want to know?
It is of no help
What do you do?

4. What next? She is given cocodamol 8/500 2 qds No help
She is tried on codydramol 2 tabs qds
She then is given dihydrocodeine 30-60mg qds
She is tried on solpadol 2 tabs qds
She then tries tylex 2 tabs qds
What next?

5. If someone needs an opioid what is the best one to start with?
What is a suitable starting dose?

6. QUIZ: What is the usual starting dose of oramorph?
Will she definitely take it? If not-why not?
Any thing you should routinely advise on, or even co-prescribe? 6

7. QUIZ ctd
You give her some oramorph to supplement her regular cocodamol 30/500 2 tabs qds.
When do you plan to revisit symptom control? How?
Next week you find that:
she has taken 10mg oramorph 4 x in the last 24 hours
What do you want to know?
What next?
What do you prescribe/try for the next 24 hours? 7

8. Now she is on MST 30mg bd. What just in case dose of oramorph should she be on?

9. QUIZ:
Now she is on MST 300mg bd. What just in case dose of oramorph should she be on?
How did she get from 30mg bd to 300mg bd?

10. QUIZ ctd
You have a patient who is clearly dying. He is unable to manage oral medicine but in fact was on no analgesia. He is uncomfortable
Where do you start?
What if he had been comfortable?
What if he had been on 30mg MST bd? 10

11. Write a prescription for the pain killer you want supplied (he was on MST 30mg bd prior to being unable to manage oral medication).
Write an authorisation so that a nurse can give him analgesia.

12. What other medicines would it be sensible to supply?
For what symptoms?