WHO treatment guides for cancer pain provide explanations of the pathophysiology of such pain, how to make adequate assessments, how to choose analgesics, and how to use the ladder. Early studies on its effectiveness demonstrated that the method proposed by the WHO offered inexpensive treatment and adequate relief for 70% to 90% of cancer patients with pain.
Adjuvant medications can be initiated as needed at any step of the ladder. These medications include antidepressants (e.g., tricyclics for acute neuropathic pain), anticonvulsants (e.g., gabapentin), and glucocorticoids (e.g., dexamethasone to reduce postoperative pain, nausea, and vomiting). The analgesic effectiveness increases with each step up on the ladder, as does the potential for medication abuse or addiction.
WHO Pain Ladder for Pain Management
The World Health Organization three-step analgesic ladder modified to exclude drugs unsafe in renal failure. Patients were treated with medications in step 1 when they rated their pain as a 1 to 4 on a 10-point scale. Patients were treated with medications in step 2 when they rated their pain as a 5 or 6 on a 10-point scale. Patients were treated with medications in step 3 when they rated their pain as a 7 to 10 on a 10-point scale.
Step 1, Mild Pain (1-4)
- Acetaminophen
- +/- Adjuvants
Step 2, Moderate Pain (5-6)
- Hydrocodone
- Oxycodone
- Tramadol
- +/- Analgesics nonopioids
- +/- Adjuvants
Step 3, Severe Pain (7-10)
- Hydromorphone
- Methadone
- Fentanyl
- Oxycodone
- +/- Analgesics nonopioids
- +/- Adjuvants
References:
- Carlson CL. Effectiveness of the World Health Organization cancer pain relief guidelines: an integrative review. J Pain Res. 2016 Jul 22;9:515-34. [Medline]
- Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management. Stepping up the quality of its evaluation. JAMA. 1995 Dec 20;274(23):1870-3. [Medline]
Created Jun 28, 2018.
