When Opioids are appropriate for Pain Managements

Chronic pain management is currently a divisive health issue due to the opioids used to treat some manifestations of pain. Many doctors and treatment professionals look to the World Health Organization (WHO) for guidance regarding such issues. First developed in 1998, the WHO guidelines for chronic pain management began to be updated in 2008 to broaden their scope based on the Delphi study in 2007.  

The WHO approaches the care of chronic pain by differentiating between malignant pain (i.e. caused by cancer or other terminal conditions) and non-malignant pain, with different scoping guidelines for children and adults. The following outcomes of chronic pain management should be considered: effectiveness of the treatment in regards to pain relief, how fast the treatment works in the alleviation of pain, how long the relief lasts, and the effect of treatment on the quality of life. Chronic pain results in disability and reduced quality of life, but the risk of treatment with certain drugs has to be weighed with the benefits gained in pain management and the types of treatments available (e.g., analgesics, opioids, intermittent therapy vs. around-the-clock therapy), depending on the type of pain experienced (e.g., neuropathic, nociceptive, episodic). However, the agency recognizes that under-treatment due to fears of opioid abuse is a reality, and is currently addressing these concerns for the new guidelines, which are expected in 2011.

The WHO currently recommends a three-step pain relief ladder to determine the appropriate treatment for chronic pain in cancer in order to avoid unnecessary opioid use and drug dependence. The approach can be expanded to non-malignant chronic pain as well, such as headaches/migraines, to avoid over-treatment.

The drugs are recommended to be given every 3 to 6 hours, and not “on demand”, in the following steps:

Step 1

Treatment with non-opioids, with or without additional drugs for fear and/or anxiety. The recommended analgesics are aspirin and acetaminophen (known as paracetamol outside of the U.S.).

Step 2

If step 1 treatment fails to alleviate pain, or the pain increases, mild opioids for moderate pain, such as codeine, can be used. Non-opioids and adjuvants for fear and anxiety can be used depending on the specifics of the case and cause of pain.

Step 3

If the previous steps fail to alleviate pain, or the pain increases, strong opioids for severe pain, such as morphine, can be used. Non-opioids and adjuvants for fear and anxiety can be used depending on the case.

The WHO estimates that the pain relief ladder is 80 to 90 percent effective. The American Chronic Pain Association also offers support and education for chronic pain and its treatments.