WHO Analgesic Ladder

The World Health Organization (WHO) ²³ developed a method for cancer pain relief consisting of a three-step treatment ladder. This approach has been used and applied in several practice settings and addresses the management of mild, moderate, and severe pain. The ladder consists of three steps and four classes of drugs:

• non-opioid analgesics (aspirin, acetaminophen, NSAIDs)
• weak opioid analgesics (codeine, oxycodone)
• strong opioids (morphine, methadone, fentanyl)
• adjuvants (antidepressants, anticonvulsants)

The first step of the ladder is for the patient with mild pain. If the pain persists after optimum treatment at that level, the patient's therapy steps up to the next level. Once the second level is not adequate to control the pain, the therapy is escalated to level three. At each level, an adjuvant therapy may be added and non-opioids may be continued. In severe pain, a course of nonopioid medication at the onset is not necessary. Instead, early use of opioids is suggested to bring the pain into tolerable range. Although the analgesic ladder was created for pain control in cancer patients, the same principles may be applied to patients with chronic nonmalignant pain.

Combination products, i.e., those that have an opioid combined with nonopioid, should be avoided in the elderly because of limited dosing available due to the ceiling dose for the nonopioid (e.g., acetaminophen total of 4 gm/day).

return to top of page