5th January 2024

WHO Analgesic Ladder

In 1986, the World Health Organisation (WHO) created a ladder for cancer pain management. It set out three stages of pain: mild, mild-moderate and moderate-severe. Options for pain management were recommended, with mild pain being treated with non-opioids, mild-moderate with weak opioids and moderate-severe with strong opioids. Adjuvant medications were recommended for use alongside every stage.

No single opioid has been proven to be more efficacious than the others. In common practice, morphine is the first opioid medication of choice. In renal disease, oxycodone may be used instead (or alfentanil, following specialist advice).

The mainstay of management in constant background pain, according to WHO, is that analgesia should be given “by the mouth” (orally), “by the clock” (at regular intervals) and “by the ladder” (using the WHO analgesic ladder in a stepwise manner).