Who pain ladder
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WHO pain ladder three steps analgesic ladder 2024
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Here is a full breakdown of the WHO Pain (Analgesic) Ladder:
WHO Analgesic Ladder
Introduced by the World Health Organization in 1986, the pain ladder is a stepwise framework for managing cancer pain (and widely applied to other pain conditions). It is built on the principle of escalating analgesic potency based on pain intensity, rather than diagnosis.
The 3 Steps
| Step | Pain Level | Drugs Used |
|---|---|---|
| Step 1 | Mild pain | Non-opioids: Paracetamol (acetaminophen), NSAIDs (e.g. aspirin, ibuprofen, diclofenac) ± adjuvants |
| Step 2 | Mild-to-moderate pain (Step 1 fails) | Weak opioids: Codeine, Tramadol + non-opioid ± adjuvants |
| Step 3 | Moderate-to-severe pain (Step 2 fails) | Strong opioids: Morphine, Oxycodone, Hydromorphone, Fentanyl + non-opioid ± adjuvants |
Adjuvants (used at any step as needed): Tricyclic antidepressants (e.g. amitriptyline), anticonvulsants (e.g. gabapentin, carbamazepine), corticosteroids, muscle relaxants - particularly useful for neuropathic pain.
The 5 WHO Principles of Analgesic Administration ("By the 5 A's")
The WHO paired the ladder with five principles for giving analgesics:
- By mouth - oral route preferred whenever feasible (simple, cheap, adjustable)
- By the clock - give on a regular schedule, not "as needed," to maintain continuous analgesia
- By the ladder - select the step based on pain intensity; move up if pain is not controlled
- For the individual - doses must be titrated to each patient's needs
- Attention to detail - vigilant reassessment of pain relief and side effects
Step 4 (Modified Ladder - widely used extension)
Many modern pain specialists add a 4th step:
- Interventional procedures: spinal cord stimulation, nerve blocks, intrathecal drug delivery, neurolytic techniques - for refractory or intractable pain that does not respond to maximal pharmacotherapy.
Key Clinical Points
- Move up, not sideways - if a drug at one step fails, escalate to the next step rather than switching to another drug at the same step.
- Morphine is the opioid of choice for moderate-to-severe cancer pain (Step 3).
- Opioid rotation may be considered if a patient has adequate pain relief from one opioid but unacceptable side effects.
- Breakthrough pain - short-acting opioids (e.g. immediate-release morphine or fentanyl) cover acute flares on top of a stable background regimen.
- Opioid-induced neurotoxicity (myoclonus, hallucinations, confusion) can occur from accumulation of opioid metabolites - consider dose reduction or opioid switching.
- Oral morphine: typically started every 4 hours, then converted to slow-release formulation (e.g. MST) every 12 hours once dose is established.
- Pethidine (meperidine) has been withdrawn from use in chronic cancer pain due to neurotoxic metabolite accumulation.
Sources:
- Cummings Otolaryngology Head and Neck Surgery (Fig. 14.1; Table 14.2)
- Bailey and Love's Short Practice of Surgery, 28th Ed.
- Scott-Brown's Otorhinolaryngology Head & Neck Surgery
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WHO Pain Ladder
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The document includes:
- Header banner with title and source info
- 3-Step ladder table with pain levels, drug classes, and examples (color-coded by step)
- Adjuvant medications table by drug class
- WHO's 5 Principles of analgesic administration
- Step 4 interventional options
- Clinical pearls (morphine dosing, breakthrough pain, opioid rotation, side effects)
- Source citations at the footer
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