What is the WHO analgesic ladder and how is it used in pain management?

The WHO analgesic ladder is a stepwise framework originally designed for cancer pain but now often used to guide analgesia in general pain management. It has three steps: Step 1 uses non-opioids like paracetamol for mild to moderate pain, Step 2 adds weak opioids like codeine and tramadol, and Step 3 uses strong opioids like morphine, oxycodone, fentanyl, and diamorphine for severe pain. The ladder is used by starting at the step appropriate to the person's pain and moving in one direction, while considering adjuvant agents to maximize effect.

The WHO analgesic ladder provides a structured, stepwise method for choosing and titrating pain medication. Although first developed for cancer pain, it is now widely applied to general pain management. At Step 1, non-opioid analgesics such as oral paracetamol are used for mild to moderate pain, and intravenous paracetamol may be used for moderate to severe pain. Step 2 introduces weak opioid drugs, such as codeine and tramadol, which act on opioid receptors to produce analgesia; these may be combined with non-opioids. Step 3 is reserved for severe pain and uses strong opioids, including morphine, oxycodone, fentanyl, and diamorphine, with dosing and frequency titrated as needed. The core concept of the ladder is to move upward in one direction according to the patient's pain intensity. Adjuvant agents, which are additional drugs or therapies given alongside the main treatment, can also be used to strengthen pain management. Clinical use of the ladder has been reviewed in recent years because many pain medicines carry risks such as dependency and misuse, so medication optimization is important.