"Pain ladder", oranalgesic ladder, was created by theWorld Health Organization (WHO) as a guideline for the use of drugs in the management of pain. Originally published in 1986 for the management ofcancer pain, it is now widely used by medical professionals for the management of all types ofpain.
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 common,over-the-counter drugs at the lowest rung, to strongopioids.
The WHO guidelines recommend promptoral administration of drugs ("by the mouth") when pain occurs, starting, if the patient is not in severe pain, with non-opioid drugs such asparacetamol (acetaminophen) oraspirin,[1] with or without "adjuvants" such asnon-steroidal anti-inflammatory drugs (NSAIDs) includingCOX-2 inhibitors. Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, a weakopioid such ascodeine,dihydrocodeine ortramadol is added to the existing non-opioid regime. If this is or becomes insufficient, a weak opioid is replaced by a strong opioid, such asmorphine,diamorphine,fentanyl,buprenorphine,oxymorphone,oxycodone, orhydromorphone, 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-opioidanalgesic.[2]
The guideline directs that medications should be given at regular intervals ("by the clock") so that continuous pain relief occurs, and ("by the individual") dosing by actual relief of pain rather than fixed dosing guidelines. It recognizes thatbreakthrough pain may occur and directs immediate rescue doses be provided.
| Step 1. | Mild pain: | Non-opioid | + | Optional adjuvant | If pain persists or increases, go to step 2. | ||
|---|---|---|---|---|---|---|---|
| Step 2. | Moderate pain: | Weak opioid | + | Non-opioid | + | Optional adjuvant | If pain persists or increases, go to step 3. |
| Step 3. | Severe pain: | Strong opioid | + | Non-opioid | + | Optional adjuvant | Freedom from pain. |
The usefulness of the second step (weak 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 weak opioid, with the possible exception oftramadol due to its unique additional actions (seetramadol § Pharmacology), could be replaced by smaller doses of a strong opioid.[2]
Not all pain yields completely to classic analgesics, and drugs that are not traditionally considered analgesics, but which reduce pain in some cases, such assteroids orbisphosphonates, may be employed concurrently with analgesics at any stage.Tricyclic antidepressants, class Iantiarrhythmics, oranticonvulsants are the drugs of choice forneuropathic pain. Up to 90 percent of cancer patients, immediately preceding death, use suchadjuvants. Many adjuvants carry a significant risk of serious complications.[2]
The ladder was developed by a team that includedJan Stjernswärd andMark Swerdlow.[3]
The pain ladder has appeared in several publications.
The original 1986 presentation of the pain ladder is on page 51 of this booklet.
Later presentations are in updated publications.