Pain is a leading reason people seek medical attention, and painkillers are the foundation of pain management in many cases. With many options to choose from, medical professionals must consider which painkillers are most appropriate for the patient's condition. Two major classifications of pain medications are nonopioids and opioids, with opioids being the strongest.
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WHO Pain Ladder
Initially developed by the World Health Organization, or WHO, for the treatment of cancer pain, the WHO pain ladder has been adapted for use in all kinds of pain management. The tool is used to match the strength of the pain reliever with the severity of the pain. For mild pain, it begins with nonopioids, including aspirin, acetaminophen (Tylenol) and nonsteroidal antiinflammatory medications, such as ibuprofen (Motrin, Advil) and naproxen (Naprosyn, Anaprox, Aleve). Moderate to severe pain may require the addition of weak or strong opioids.
Opioids come naturally from the opium poppy or are synthetically created to resemble and act like opium. Opioids relieve pain by blocking pain signals in the area of the brain that controls emotion. Because they may cause euphoria and have the potential to be habit forming, opioids require a prescription. Physical dependence occurs when the body becomes used to having the drug and experiences withdrawal symptoms when it is abruptly stopped.
Weak opioids are used to treat mild to moderate pain. Codeine and tramadol (Ultram, Ultracet) are weak opioids and are about twice as potent as nonopioids. They work well for pain in muscles and joints, such as sprains and osteoarthritis, as well as pain in internal organs, which may feel dull, sore and vague.
Strong opioids are used for severe pain associated with trauma, major surgery and cancer. Morphine -- the gold standard of opioids -- is one of the oldest and most versatile of strong opioids. It can be given by mouth, under the tongue, intravenously, by injection and even rectally. Intravenous morphine is often used to treat acute pain associated with heart attack. Quick-acting oral preparations help relieve breakthrough cancer pain in as little as 15 minutes. Long-acting preparations, such as MS Contin and Duramorph, help provide continuous relief from severe pain from cancer and other serious conditions.
Synthetic Strong Opioids
Synthetic strong opioids include hydromorphone (Dilaudid) and fentanyl (Duragesic). Hydromorphone can be given orally or by injection for quick relief of acute pain. Fentanyl is worn as a transdermal patch for protracted pain relief. In recent years, methadone (Dolophine, Methadose) has been used more often for chronic pain management because people do not require increased doses over time as they often do with other strong opioids.
Low-dose, strong opioids are commonly combined with nonopioids, such as acetaminophen, ibuprofen or aspirin, to treat moderate pain. Hydrocodone (Vicodin, Lortab, Norco) and oxycodone (Percocet, Percodan, Combunox) are examples of these mixed opioids. Hydrocodone is the most commonly prescribed opioid for short-term pain associated with injury, dental problems and minor surgical procedures.
REFERENCES & RESOURCES
- Clinical Coach for Effective Pain Management; Paul Arnstein, R.N., Ph.D.
- Goodman & Gilman’s The Pharmacological Basis of Therapeutics; Laurence Brunton, et al., eds.
- National Institute on Drug Abuse: What Are Opioids?
- World Health Organization: WHO’s Pain Ladder for Adults
- American Academy of Pain Medicine