Posted in Psychology & Medicine

Analgesic Ladder

Quite possibly the most common condition that a physician needs to treat is pain. Being the main way for the body to communicate that there is something wrong, pain can take various forms to make us suffer physically. The best way to make this pain go away is to treat the underlying cause, but often the cause is unclear and we need to manage the symptoms first.

Just as there are many kinds of pain, there are numerous different types of analgesics, or painkillers. Doctors and nurses take into account various factors to decide which analgesia to use, how much to give and how often to give it. For example, opioids (e.g. morphine) are one of the most effective pain-reliefs, but it comes with many adverse effects such as vomiting, constipation, drowsiness, slowing of breathing and potentially death. To facilitate this, the World Health Organisation created the concept of the “Analgesic Ladder”, establishing some simple rules to guide appropriate analgesia administration.

The ladder has been adapted to accommodate for new research and advancing pain-relief methods, but the general principle remains the same.

First, simple non-opioid medications should be given orally and regularly. Almost always, the first-line analgesia is paracetamol (acetaminophen in USA). It is an effective pain-relief, especially when it is taken regularly four times a day, while being extremely safe as long as it is not taken above the maximum dosage (4 grams/day). As effective as it is, people often neglect to take it regularly as directed, or take it too late when the pain has progressed to a severe level, hence the common misunderstanding that it is weak.

The next step of non-opioid medications are non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen or diclofenac. These medications work particularly well for musculoskeletal pain, muscle aches from viral illnesses and simple headaches. However, they are prone to causing stomach upsets, ulcers and kidney dysfunction. They can also exacerbate asthma in some patients. It should be taken in conjunction with paracetamol as they have a synergistic effect. Because of its gastrointestinal side effects, it is recommended to be taken after meals.

When paracetamol and NSAIDs are ineffective at easing the pain, a weak, oral opioid such as codeine or tramadol is added in. These medications are powerful, but often have undesirable side effects such as nausea and vomiting, constipation, confusion and agitation.

As we step up the ladder, we introduce stronger opioids. This includes oral options such as sevredol and oxycodone, to intravenous options such as IV morphine and fentanyl. As effective as these medicines are, they must be used with caution given the significant adverse effects such as opioid narcosis, where a patient can stop breathing or enter a coma.

Other than opioids, there are various other options of pain relief that may be explored as adjuncts. Neuropathic pain from nerve damage is notorious for being opioid-resistant, so medications such as gabapentin or tricyclic acids (traditionally an antidepressant) may be used. Ketamine is sometimes used as it has analgesic properties. A PCA (patient-controlled analgesia) pump with morphine or fentanyl may be more effective to optimise the timing of doses. Long-acting opioids such as methadone may be considered. Lastly, nerve blocks with local anaesthesia, such as epidurals, are often used in conjunction to reduce the need for opioids.

Pain is an extremely useful evolutionary tool as it allows as us to avoid harm, but it can create just as many problems. The analgesic ladder helps health professionals better manage pain so that patients do not have to suffer as much while they are being investigated and treated.

Posted in Psychology & Medicine


In 1976, an outbreak of a viral illness was identified in Sudan. Patients would present with symptoms of high fever, headache, vomiting, diarrhoea and a spotted rash, but would rapidly deteriorate in health. Within days, patients showed signs of decreased blood clotting, such as bleeding from intravenous line sites, having blood in their vomit and stool, or bleeding from essentially any bodily orifice. If untreated, patients would die within two weeks of shock (very low blood pressure), kidney failure or bleeding into the brain. The outbreak killed 151 people before it disappeared.

Later in the year, a headmaster at a school in Zaire developed a similar disease after travelling to the Ebola River. He died two weeks later. Soon after, people he came in contact with after his trip died of similar symptoms. The World Health Organisation investigated this epidemic and realised that the disease was caused by a new type of virus, which was named ebola virus. Due to its symptoms, the disease caused by the virus is named ebola haemorrhagic fever.

Since the discovery of the disease, occasional ebola outbreaks were seen in various parts of Africa, mainly around Congo and Uganda. Each time, the disease would rapidly claim the lives of hundreds of people and then vanish. This is because ebola virus was so effective in killing people (with a death rate of 90% in one outbreak), that it would kill the infected person before they spread the disease further.

The virus can be spread through any bodily fluid, including blood, tears, semen and sweat. Because of this, once an infected patient is brought into hospital, the disease can spread rapidly throughout the building and infect many patients and hospital staff if proper precautions are not taken. Fortunately, the virus is not known to spread when the patient is in the incubation period (when they are infected but have not shown symptoms yet).

The origin of the virus has been traced back to fruit bats (like many other serious viruses). Fruit bats have extremely powerful immune systems to protect their cells from the harmful metabolites produced by flying, allowing bats to harbour deadly viruses without succumbing to them. These viruses have also evolved to withstand the high temperatures produced by flying (which involves significant muscle work), meaning they can easily survive the high fevers they cause in humans. The transmission from bats to human in modern times is likely attributed to deforestation and humans encroaching into the bats’ native territory.

The current epidemic that originated from West Africa is the biggest ebola outbreak so far, having infected over 9000 people and claiming the lives of over 4500 people (October 14, 2014). However, this is likely a grossly underestimated number. The epidemic is focussed mainly in Guinea, Sierra Leone, Liberia and surrounding countries, but has infected foreign workers and volunteers who have been repatriated to be treated in their home country.

Despite a robust effort from the WHO to try and curb this epidemic, the infection rate continues to climb due to various factors, such as traditional funeral rites involving touching the deceased person’s body, which is still infective after death. There are currently no effective vaccines or treatments and the only thing that can be done is supportive treatment in an intensive care unit where the patient can be adequately hydrated and monitored. Like with most communicable diseases, the most effective treatment is preventing the disease from spreading through education, rigorous infection control protocols and improved healthcare systems in the affected countries.