Pain ladder

"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 ladder

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.