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 7090% effective14
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

Adjuvants

To help calm fears and anxiety, adjuvant

drugs may be added at any step of the
ladder

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.
2.
Opioids reduce nociceptive transmission through inhibition at opioid
receptors in the brainstem, spinal cord and perhaps peripheral nerves.

Opioids for mild-to-moderate pain are used in combination with a nonopioid analgesic, such as paracetamol, at the second step of the ladder.
There are numerous combination step 2 analgesics available, however
combinations may increase side-effects yet may not significantly increase
efficacy.5
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
There is some debate as to whether the second step of the ladder adds
value.2,4
One might argue it would make sense to simply add very small doses of
strong opioids to non-opioids (for example, morphine 2.5mg). The added
value of step 2 probably lies in the availability of these drugs worldwide
rather than in superiority of effect.4 In moderate pain it is perfectly
reasonable to commence small doses of strong opioids (licensed for
moderate pain) without recourse to the weaker opioids first.4,6
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

References

1. WHO Pain Relief Ladder for cancer pain relief. Available

at: www.who.int/cancer/palliative/painladder/en/ (accessed 14 April 2015).
2. Vargas-Schaffer G. Canadian Family Physician 2010;56(6):514517,
e202205.
3. Azevedo So Leo Ferreira K, Kimura M, et al. Supportive Care in
Cancer 2006;14(11):10861093.
4. Eisenberg E, Marinangeli F, et al. Time to Modify the WHO Analgesic
Ladder? Pain: Clinical Updates 2005;13(5):14.
5. British National Formulary online March 2015. Available
at: www.evidence.nhs.uk/formulary/bnf/current/4-central-nervoussystem/47-analgesics/471-non-opioid-analgesics-and-compoundanalgesic-preparations/compound-analgesic-preparations (accessed 14
April 2015).
6. Maltoni M, Scarpi E, et al. Supportive Care in Cancer 2005;13(11): 888
894.

Date of preparation: September 2015; MINT/PAEU-14003

SUMBER :
http://www.paineurope.com/tools/who-analgesic-ladder