Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Palliative cancer care - pain - Management
How do I manage persistent pain in a non-emergency situation?

  • Prescribe analgesia for continuous pain on a regular basis, in addition to as-required analgesia.
  • Consider a stepwise approach, using the World Health Organization (WHO) analgesic ladder. Start at the appropriate point of the analgesic ladder, moving up the ladder when the maximum dose at each step is reached until the person is comfortable. The steps are:
    • Non-opioid analgesic: paracetamol and/or nonsteroidal anti-inflammatory drug (mild pain).
    • Weak opioid, with or without a non-opioid analgesic (mild-to-moderate pain).
    • Strong opioid, with or without a non-opioid analgesic (severe pain).
  • At any stage, consider the addition of a non-opioid adjuvant drug (any drug that has a primary indication other than for pain management but is analgesic in some painful conditions: for example, a tricyclic antidepressant for neuropathic pain).
  • Review regularly (consider a telephone call if appropriate), step treatment up or down as necessary, and stop unnecessary medication that has not worked.
Basis for recommendation
  • The recommendation to use analgesia at regular intervals for continuous pain is based on the British National Formulary and Palliative Care Formulary [Twycross and Wilcock, 2007; BNF 56, 2008].
  • This stepwise approach is based on the principles of the WHO analgesic ladder (based on the consensus of international expert opinion and clinical practice) that aims to match treatment to the intensity of the pain [WHO, 1996; WHO, 2003]. When the WHO ladder is used appropriately, at least 70% of people achieve benefit [Quigley, 2005].
  • The correlation of mild, moderate, and severe pain to the steps of the WHO ladder is used in a guideline from the Scottish Intercollegiate Guidelines Network [SIGN, 2008]:
    • Non-opioid analgesic drugs: trial data of non-opioid (paracetamol and nonsteroidal anti-inflammatory drugs [NSAIDs]) analgesia in people with cancer-related pain are limited, but evidence supports the general analgesic effect of these drugs [MeReC, 2000; Bandolier, 2007; McNicol et al, 2007], and guidelines and experts recommend their use. Non-opioid analgesic drugs may have synergistic effects when used with opioids, allowing better pain relief to be achieved at lower doses of opioid and therefore reducing opioid adverse effects [SIGN, 2008].
    • Weak opioid drugs: there is debate about the use of weak opioids at step 2 of the WHO analgesic ladder because there is little evidence that they are more effective than the drugs (paracetamol and/or an NSAID) used at step 1 [MeReC, 2000]. However, weak evidence suggests that using an opioid in combination with paracetamol, with or without an NSAID, may reduce the dose of opioid required and therefore reduce adverse effects [SIGN, 2008]. An alternative strategy is to prescribe a low dose of a strong opioid. This approach may be more effective in relieving pain, but there is more potential for adverse effects.
    • Strong opioid drugs: the success of the WHO approach to pain management has been attributed to using strong oral opioids for severe pain [Hanks et al, 2001].

© NHS Institute for Innovation and Improvement