Palliative care: WHO pain 'ladder'

Last updated: Thursday, January 21, 2016

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

The World Health Organisation Guidelines (WHO) on the management of cancer pain recommend the use of analgesia ‘by mouth, by the clock and by the analgesic ladder’. It describes three types of analgesic:

  • 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). 

Patients should continue to take oral medication for as long as possible, prescribed at regular intervals, according to the WHO three-step analgesic ladder shown below. 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.

Step 1
Mild pain
 +/- adjuvants
Step 2
Mild to moderate pain
Paracetamol, NSAIDs,  +/- adjuvants
Weak opioids (e.g. codeine)
Step 3
Moderate to severe pain
Paracetamol, NSAIDs, +/- adjuvants
Strong opioids (e.g. morphine)

Step one: 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.

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Step two: There is some debate about the need for step two of the WHO ladder, and 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 helpful 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 three: 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.