WHO Ladder, Opioids, Neuropathic Pain & Gout Simplified for MSRA

Key Points:

1. WHO Analgesic Ladder

• Step 1 (Mild Pain): Non-opioid analgesics (e.g. paracetamol, NSAIDs)

• Step 2 (Moderate Pain): Weak opioids ± non-opioids (e.g. codeine)

• Step 3 (Severe Pain): Strong opioids (e.g. morphine)

• Important: For severe pain (e.g. bone metastases), escalate directly to strong opioids.

2. Opioid Use and Contraindications

• Morphine Contraindication: Severe acute bronchial asthma

• Alternative to Morphine (if excessive sedation): Oxycodone

• Fentanyl Patches:

  • Should be avoided in patients still in pain (not suitable for acute pain due to slow onset)

  • Not used in neonates

3. Neuropathic Pain Management

• First-line: Amitriptyline

• Other options: Gabapentin, Carbamazepine (specific for trigeminal neuralgia)

4. Trigeminal Neuralgia

• First-line treatment: Carbamazepine

5. Gout

• Most commonly affected joint: First metatarsophalangeal joint

• First-line for acute gout with PUD history: Oral colchicine

• Do NOT stop during acute attack if already established: Allopurinol

• Medication increasing risk of gout: Diuretics

• Lifestyle modification: Reduce alcohol intake

6. General Pain Management

• Bone metastasis pain: Morphine is first-line; bisphosphonates and radiotherapy have adjunct roles.

• Muscle spasm pain: Baclofen

• Sciatica: Avoid gabapentin

Important Considerations:

• WHO analgesic ladder guides systematic pain escalation.

• Strong opioids are indicated for cancer-related severe pain directly.

• Always check contraindications before opioid prescribing.

• Differentiate neuropathic vs nociceptive pain for appropriate pharmacological choices.

• NSAIDs are avoided in peptic ulcer patients; colchicine or corticosteroids are safer alternatives for gout.

• Do not stop allopurinol during acute gout flares if already established on it.

Diagnostic Approach:

1. Assess pain severity (mild, moderate, severe).

2. Identify pain type (nociceptive, neuropathic, mixed).

3. Evaluate contraindications (e.g. asthma for morphine).

4. Review current medications and comorbidities (e.g. PUD in gout patients).

5. Consider cancer-related red flags (e.g. bone metastasis).

Management:

Pain Management Plan

• Mild pain: Start with non-opioids (paracetamol ± NSAIDs)

• Moderate pain: Add weak opioids (e.g. codeine)

• Severe pain: Start strong opioids (morphine; oxycodone as alternative if sedation occurs)

Neuropathic Pain

• First-line: Amitriptyline

• Specific conditions: Carbamazepine for trigeminal neuralgia

Gout

• Acute attack with PUD: Oral colchicine preferred

• Avoid stopping: Allopurinol during acute attacks

• Long-term: Lifestyle modification (reduce alcohol), urate-lowering therapy if indicated

Bone Pain

• Cancer metastasis: Morphine first-line; bisphosphonates and radiotherapy adjuncts

Muscle Spasm

• Medication: Baclofen