If treating chronic pain, KTT21 discourages use of the WHO pain ladder as it is intended for cancer pain. The BNF notes that the “WHO analgesic ladder is widely used to guide the basic treatment of acute and chronic pain; whilst there is little evidence to support its use in chronic pain it may provide an analgesic strategy for non-specialists”.22,34,35

The NICE CKS ‘Analgesia – mild-to-moderate pain’ (September 2015) does follow a stepwise strategy with paracetamol as the starting point. This can be substituted for low-dose ibuprofen or a full therapeutic dose of an opioid (eg codeine 60 mg every 4–6 hours to a maximum 240 mg daily) if an NSAID is unsuitable. The pathway then combines analgesics, or switches ibuprofen for naproxen or other NSAID.36

Further points to consider when prescribing analgesics include:36

·       aim to treat the underlying cause of the pain where possible

·       have a full clinical assessment for patients with continuous pain

·       achieve full therapeutic dose of an analgesic before considering switching the drug

·       check for adherence before switching

·       consider gastric irritation with NSAIDs – use a proton pump inhibitor if appropriate

·       take care with opioids around dependence and the appropriate starting dose, especially in the elderly.