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WHO analgesic ladder

The cancer pain relief programme of the WHO advocates a three-step ‘analgesic ladder’ in an attempt to improve the worldwide management of pain due to cancer (figure 1).1

Figure 1. WHO analgesic ladder for cancer pain

The WHO pain ladder is a framework for providing symptomatic pain relief. The three-step approach is inexpensive and 70–90% effective1–4

By mouth

The oral route is preferred for all steps of the pain ladder1,2

By the clock

Cancer pain is continuous - analgesics should be given at regular intervals (every three to six hours), not on demand1


To help calm fears and anxiety, adjuvant drugs may be added at any step of the ladder


Adapted from: World Health Organisation1

The underlying principle is that, following good pain assessment and thorough knowledge of a small number of analgesics, a simple approach should produce pain relief in the majority of patients.2 In essence, the approach combines two modalities of pain relief:1

  1. Non-opioid analgesics, such as NSAIDs or paracetamol, reduce inflammation and/or prostaglandin synthesis and thereby reduce nociceptive stimuli.5
  2. Opioids reduce nociceptive transmission through inhibition at opioid receptors in the brainstem, spinal cord and perhaps peripheral nerves.5

Opioids for mild-to-moderate pain are used in combination with a non-opioid analgesic, such as paracetamol, at the second step of the ladder.

If regular maximum doses of opioids for mild-to-moderate pain do not achieve adequate analgesia, then they should be replaced with an opioid for moderate-to-severe pain, such as morphine.1

Although the WHO analgesic ladder was developed for use in cancer pain, a stepwise approach is probably equally applicable to the management of chronic pain due to other causes.2


1. WHO Pain Relief Ladder for cancer pain relief. Available at: www.who.int/cancer/palliative/painladder/en/ (accessed 17 August 2017).
2. Vargas-Schaffer G. Canadian Family Physician 2010;56(6):514–517, e202–205.
3. Azevedo São Leão Ferreira K, Kimura M, et al. Supportive Care in Cancer 2006;14(11):1086–1093.
4. Eisenberg E, Marinangeli F, et al. Pain: Clinical Updates 2005;13(5):1–4.
5. Dahl V, Raeder JC. Acta Anaesthesiologica Scandinavica 2000;44(10):1191–1203.


Date of preparation: October 2017; MINT/PAEU-17047