The document discusses pain management as a fundamental right for patients and outlines various pharmacological agents used as analgesics. It introduces the WHO pain ladder for classifying pain severity and managing pain effectively, starting from non-opioid medications like paracetamol and ibuprofen, to strong opioids like morphine. Additionally, it highlights the role of adjuvant drugs, including antidepressants and steroids, in pain management.

1. Pain management
To be pain free is the right of every patient and should be the first step of management regardless of the
diagnosis. In this post we discuss various pharmacological agents that are commonly used as analgesics.
WHO has coined the term pain ladder which classifies pain according to the severity and helps a clinician
to manage pain in a better way. It was originally described for the management of cancer pain, but is
now widely used by medical professionals for the management of all types of pain.
The principle is to start from the bottom of the ladder, and to climb the ladder if pain is still present.
Figure showing WHO pain ladder principle for management of pain.
Let us discuss commonly used analgesics –
Non opiods
Paracetamol: It has a well-known analgesic property and a week anti-inflammatory effect. It is
better toleratedin patients in whom excessive gastric acid secretion or prolongation of bleeding
time may be a concern.Paracetamol hepatotoxicity the most common cause of acute liver
failure in both the United States and the United Kingdom.The common adult dose is 500 mg to
1000 mg. The recommended maximum daily dose, for adults, is 4000 mg.
NSAIDs 
Ibuprofen: Ibuprofen blocks the enzyme that makes prostaglandins (cyclooxygenase), resulting
in lower levels of prostaglandins. As a consequence, inflammation, pain and fever are reduced.
The usual adult dose is 200 or 400 mg every 4 to 6 hours.Ibuprofen should be taken with meals
to prevent stomach upset.
Diclofenac: Very commonly given analgesic. It is mostly given in acute conditions in an
intramuscular form at a dose of 75 mg. Also available as sustained released tablets.

2. Aspirin: often used as analgesic to relieve minor aches and pains, as an antipyretic to reduce
fever, and as an anti-inflammatory medication.
Weaker opioids
Tramadol: is a centrally acting synthetic opioid analgesic used in treating severe pain.Like
morphine, tramadol binds to receptors in the brain (opioid receptors) that are important for
transmitting the sensation of pain from throughout the body to.
Codeine: is an opiate used for its analgesic, antitussive, and antidiarrheal properties.
Strong opioids
Morphine: is a potent opiate analgesic medication. Morphine is primarily used to treat both
acute and chronic severe pain. It is also used for pain due to myocardial infarction and for labor
pains. Common side effects are addiction and constipation.
Adjuvant drugs 
Antidepressants: Antidepressants increase the levels of certain brain chemicals that improve
mood and regulate pain signals. Low doses of antidepressants also relieve pain, although it is
not known exactly how. Commonly used drugs are Amitriptyline and Imipramine.
Anticonvulsants: Anticonvulsants control cancer pain by changing the way sodium and calcium
travel across the surface of nerve cells in the brain. The nerve cells send fewer signals, and the
brain senses less pain. Commonly used drugs are Carbamazapine, Gabapentine and Phenytoin.
Steroids: Steroids are particularly useful as adjuvant therapy for metastatic bone pain,
neuropathic pain, and visceral pain. Dexamethasone is the most commonly prescribed
corticosteroid for pain, but prednisone or prednisolone can also be used.
Muscle relaxants: Muscle relaxants include drugs that reduce muscle spasm (for example
benzodiazepines such as diazepam, alprazolam, lorazepamand non-benzodiazepines such as
metaxalone or a combination of paracetamol and orphenadrineand drugs that prevent
increased muscle tone (baclofen and dantrolene).
Exercises.
Psychological support.
Acupuncture.