Palliative care: WHO pain ladder

Last updated: Sunday, January 03, 2021

Pain is a complex phenomenon. It has been shown that people with advanced disease have many different types of pain and several factors can influence their pain, such as anxiety. It is important to diagnose the underlying cause and severity of each pain before choosing treatment. Some pain responds only partially or poorly to opioids (e.g. neuropathic pain).

The WHO pain ladder, introduced in 1986 for the management of cancer pain, divides analgesics into three groups:
  • Non-opioids are essentially NSAIDs and paracetamol. 
  • Opioids range from weak ones (e.g. codeine, dihydrocodeine) to strong (e.g. morphine, oxycodone). 
  • Adjuvants help to relieve pain in certain specific circumstances (e.g. dexamethasone for bone pain, amitriptyline for neuropathic pain). 

The original version of the WHO guidelines also included a suggested pain ladder as shown below, which can be used as a general guide to pain management based upon pain severity. Subsequent updates to the guidelines have highlighted the need to tailor analgesics according to the individual patient’s needs. 

Therefore 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 (e.g. don’t swap from codeine to dihydrocodeine). Consider the additional use of adjuvants at all steps, and continue with regular paracetamol and NSAIDs at each step if effective and safe. 

WHO pain ladder

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.
Step 1: Regular paracetamol is the first-line analgesic for patients with mild pain. NSAIDs are especially valuable in patients with an inflammatory component to their pain (e.g. bone pain), but come with side effects that need to be taken into account. The combination of both paracetamol and an NSAID can be particularly effective.

ⓒCrown copyright 2017
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).

If step two is omitted then the patient will need to be started on a lower dose of a strong opioid.

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 as long as it is titrated carefully, and that increased doses give increased pain relief without unacceptable side effects.