Palliative care: WHO pain ladder
In 1986 the WHO published the first edition of its guideline specifically on managing cancer pain. This highlighted the importance of effective drug and non-drug management and included a 3 step 'analgesic ladder'.
A copy of the ladder is reproduced below. It can be used to guide pain management based upon pain severity. Subsequent updates to the WHO guideline have highlighted the need to tailor analgesics according to an individual patient’s needs.
The guideline divides analgesics into the following groups:
Step 2: There is some debate about the need for this step as there is no pharmacological need to prescribe a weak opioid before progressing to a strong opioid.
However, in some situations weak opioids may provide sufficient analgesia; and in others it may be useful to include step two to help manage the beliefs held by some patients about the use of strong opioids. If regular paracetamol has helped to control a patient’s pain, then compound paracetamol-opioid preparations may be prescribed if they contain therapeutic doses of opioid (e.g. co-codamol 30/500 rather than 8/500).
Patients who omit step two (i.e those that are opioid-naïve) will need to be started on lower doses of strong opioids.
Step 3: Morphine is often the strong oral opioid of choice for the management of severe pain. The combined use of regular modified-release and ‘when required’ immediate-release morphine allows effective symptom control for most patients. There is no maximum morphine dose provided it is titrated carefully, and that increased doses give increased pain relief without unacceptable side effects.
- Non-opioids In the UK these include NSAIDs and paracetamol.
- Opioids These range from 'weak' (e.g. codeine, dihydrocodeine, tramadol) to 'strong' in their potency (e.g. morphine, oxycodone, fentanyl).
- Adjuvants These help to relieve pain in certain specific circumstances (e.g. dexamethasone for bone pain, amitriptyline or sodium valproate for neuropathic pain).
Patients should start on the step of the ladder most appropriate to their level of pain. If a drug fails to relieve the pain, patients should move up one step rather than across the ladder. Consider the additional use of adjuvants at all steps, and regular paracetamol and/or NSAIDs if effective and safe. Analgesics should ideally be given by mouth and administered at appropriate fixed intervals of time, taking into account the patient’s waking hours and bedtime ('by the clock, by the mouth, by the ladder').
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| WHO pain ladder |
Step 1: Non-opioids such as paracetamol or NSAIDs may be given with or without an adjuvant.
NSAIDs are especially valuable in patients with an inflammatory component to their pain (e.g. bone pain) taking into account their side effect profile. In patients with cancer pain, it is unknown if oral paracetamol adds to the analgesic effect of NSAIDs but some experts consider it unlikely.
Step 2: There is some debate about the need for this step as there is no pharmacological need to prescribe a weak opioid before progressing to a strong opioid.
However, in some situations weak opioids may provide sufficient analgesia; and in others it may be useful to include step two to help manage the beliefs held by some patients about the use of strong opioids. If regular paracetamol has helped to control a patient’s pain, then compound paracetamol-opioid preparations may be prescribed if they contain therapeutic doses of opioid (e.g. co-codamol 30/500 rather than 8/500).
Patients who omit step two (i.e those that are opioid-naïve) will need to be started on lower doses of strong opioids.
Step 3: Morphine is often the strong oral opioid of choice for the management of severe pain. The combined use of regular modified-release and ‘when required’ immediate-release morphine allows effective symptom control for most patients. There is no maximum morphine dose provided it is titrated carefully, and that increased doses give increased pain relief without unacceptable side effects.