"Pain ladder", or analgesic ladder, was originated by the World Health Organization (WHO) to describe its guideline for the use of drugs in the management of pain. It was originally applied to the management of cancer pain, but is now widely used by medical professionals for the management of all types of pain.
The general principle is to start with first step drugs, and then to climb the ladder if pain is still present. The medications range from household, over-the-counter drugs with minimal side-effects at the lowest rung, to powerful opioids.
The WHO guidelines recommend prompt oral administration of drugs when pain occurs, starting, if the patient is not in severe pain, with non-opioid drugs such as paracetamol (acetaminophen), dipyrone, non-steroidal anti-inflammatory drugs (NSAIDs) or COX-2 inhibitors. Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, a mild opioid such as codeine phosphate, dextropropoxyphene, dihydrocodeine or Tramadol are added to the existing non-opioid regime. If this is or becomes insufficient, a mild opioid is replaced by a stronger opioid, such as morphine, diamorphine (heroin), fentanyl, buprenorphine, oxymorphone, oxycodone, hydromorphone, while continuing the non-opioid therapy, escalating opioid dose until the patient is pain free or at the maximum possible relief without intolerable side effects. If the initial presentation is severe pain, this stepping process should be skipped and a strong opioid should be started immediately in combination with a non-opioid analgesic.
Bottom rung of ladder (mild pain): Non opioid +/- adjuvant
Middle rung of ladder (moderate pain): Weak opioid +/- non opioid +/- adjuvant
Highest rung of ladder (severe pain): Strong opioid +/- non opioid +/- adjuvant
The usefulness of the second step (mild opioid) is being debated in the clinical and research communities. Some authors challenge the pharmacological validity of the step and, pointing to their higher toxicity and low efficacy, argue that a mild opioid, with the possible exception of Tramadol due to its unique action, could be replaced by smaller doses of a strong opioid.
Not all pain yields completely to classic analgesics, and drugs that are not traditionally considered analgesics, but which reduce pain in some cases, such as steroids or bisphosphonates, may be employed concurrently with analgesics at any stage. Tricyclic antidepressants, class I antiarrhythmics, or anticonvulsants are the drugs of choice for neuropathic pain. Up to 90 percent of cancer patients, immediately preceding death, use such adjuvants. Many adjuvants carry a significant risk of serious complications.
- WHO guidelines:
- World Health Organization (1996). Cancer pain relief. With a guide to opioid availability (2 ed.). Geneva: WHO. ISBN 92-4-154482-1.
- World Health Organization (1998). Cancer pain relief and palliative care in children. Geneva: WHO. ISBN 978-92-4-154512-9.
- Schug SA & Auret K. Clinical pharmacology: Principles of analgesic drug management. In: Sykes N, Bennett MI & Yuan C-S. Clinical pain management: Cancer pain. 2nd ed. London: Hodder Arnold; 2008. ISBN 978-0-340-94007-5. p. 104–22.