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The World Health Organization (WHO) in Geneva, Switzerland, has developed a step-up approach to pain management, which starts with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and then moves to more powerful drugs until pain relief is achieved. WHO’s approach is as follows:
Step 1. Use acetaminophen, aspirin, or another NSAID for mild to moderate pain. Adjuvant drugs to enhance analgesic efficacy, treat concurrent symptoms that exacerbate pain, and provide independent analgesic activity for specific types of pain may be used at any step.
Step 2. When pain persists or increases, an opioid such as codeine or hydrocodone should be added to (not substituted for) the NSAID. Opioids at this step are often administered in fixed-dose combinations with acetaminophen or aspirin because this combination provides additive analgesia. Fixed-combination products may be limited by the content of acetaminophen or NSAID, which may produce dose-related toxicity.
Step 3. When a higher dose of an opioid is necessary, the third step calls for separate dosage forms of the opioid and non-opioid analgesic in order to avoid exceeding maximally recommended doses of acetaminophen or NSAID.
Step 4. Pain that is persistent, or moderate to severe at the outset, should be treated by increasing opioid potency or using higher dosages. Drugs such as codeine or hydrocodone are replaced with more potent opioids (usually morphine, hydromorphone, methadone, fentanyl, or levorphanol).
According to WHO, medications for persistent cancer-related pain should be administered on an around-the-clock basis, with additional "as-needed" doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain. Patients who have moderate to severe pain when first seen by the clinician should be started at the second or third step of the ladder.