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WHO Pain Relief Ladder? 5 thing to know

Last Updated on June 22, 2022 by Nurse Vicky


WHO Pain Relief Ladder?  5 things to know


WHO pain relief ladders are an easy way to compare different types of medications for chronic pain. The first level is comprised of strong opioids such as morphine.

The second level includes nonpharmacologic interventions and adjuvants.

These drugs all differ in their effectiveness and cost.

Read on to learn more about each type of treatment and the WHO pain relief ladder.

You can also check out an online article on how these medications stack up in their categories.



he WHO pain relief ladder consists of four rungs, each addressing a specific type of pain.

begin at the lowest rung and typically start with nonopioid analgesics such as acetaminophen and NSAIDs.

If these do not produce analgesia, the clinician may switch to a stronger opioid, called an adjuvant.

Alternatively, a patient may receive an intravenous opioid for moderate or severe pain.

While combinations of NSAIDs and analgesics are effective for some patients, it also adds to the complexity of pain management.

A patient with a complicated pain condition may benefit from adjuvants or novel drug formulations to help manage their pain.

However, these drugs may not be available or affordable in some countries.

In these countries, a revised pain relief ladder is essential.

It should also be robust enough to help clinicians in remote areas who do not have access to these medications.

Strong opioids

strong opioidsT

he WHO pain relief ladder currently consists of four steps, each of which is comprised of two drugs:

a non-opioid and a strong opioid.

These drugs are effective for mild to moderate pain and are combined with non-steroidal anti-inflammatory drugs or acetaminophen.

While they provide analgesia for up to 30 days, their “ceiling effect” limits their use.

Moreover, escalating from NSAIDs to opioids may not result in improved analgesia.

The WHO pain relief ladder is flawed and does not account for every patient’s unique needs.

However, it does work well for the most part, if used properly.

There are several reasons why opioids are so widely used.

They are an excellent way to manage pain, but not all opioids are equally effective for every patient.

And, when used correctly, they are highly effective. That’s why we should use them.

Combination treatment

combination treatmentS

ome patients with chronic pain have found relief from multiple drugs in combination therapy. Combined treatments are recommended by health professionals.

These therapies include several medications in combination and lifestyle changes. Other types of treatment may include psychological treatments and rehabilitation.

While there is little evidence that a particular treatment is superior to another, these treatments are often recommended in combination with other pain management strategies.

This article discusses some of the different types of treatments and what to look for in combination therapy.

In clinical practice, combination therapy is common for patients with NeP.

Although existing guidelines for pain management do not recommend combination therapy, a Delphi consensus process of six Danish pain experts showed some evidence that certain combinations are effective.

The process is a way of aggregating expert knowledge and differing opinions.

The Delphi process ensures the integrity of the participants’ opinions, as they were anonymous and thus prevented any potential dominance by one or more experts.

Nonpharmacologic interventions

The current opioid epidemic is challenging conventional thinking about pain management and necessitates a rethinking of the WHO analgesic ladder.

The WHO guidelines focus on the quality of life as a measure of pain control, which is a bidirectional process that extends to acute pain.

Generally, stronger analgesia is used as initial therapy for acute pain and toned down as needed.

The WHO alsorecommends a step-wise approach for chronic pain management, with de-escalation of the treatment regimen as needed.

The WHO analgesic ladder is widely accepted for the treatment of nociceptive pain.

This treatment scheme generally starts with morphine in Step 3, reduces to codeine in Step 2, and concludes with paracetamol in Step 1.

In addition to the WHO pain relief ladder, the WHO guidelines recommend that physicians offer appropriate patient education on how to use certain drugs.

For example, patients should be educated about the risks of different drugs and how to avoid them.

ESRD patients


esrd patients


A large number of ESRD patients report having high levels of pain, yet the impact of pain on quality of life is often under-treated.

Although many pain clinicians think that the WHO analgesic ladder is applicable to ESRD patients, this has never been validated.

In this study, we assessed pain levels and types in 45 hemodialysis patients.

The findings are discussed in this report.

Pharmacologic treatments for ESRD patients are complex and lack good-quality trials.

The limitations of current therapies, including neuropathic pain, require careful consideration of pharmacological properties, metabolism, dialysis, and potential drug-drug interactions.

Furthermore, pain management in this population requires continuous monitoring due to the fact that the treatment for ESRD patients is often unpredictable.

In the interim, the WHO recommends a multi-drug approach for ESRD patients.

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