Analgesic ladder

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WHO Analgesic Ladder

The analgesic ladder is a conceptual framework for the prescription of analgesic drugs, first put forward by the World Health Organisation.

Conceptually, the analgesic ladder is an attempt to match the ceiling effect of analgesic drugs to the degree of pain present. If pain is severe or analgesia ineffective, then an ascent of the ladder is recommended.

Its advantages include:

  • Simplicity, in that only a few, widely-known drugs are employed
  • Applicability to a wide variety of situations and prescribers worldwide
  • Safety, in that safer drugs are used first
  • Emphasis on multimodal analgesia, the concept that pain is best treated, not by a single drug or therapy, but by combinations, which maximise efficacy whilst keeping side-effects low

Its disadvantages include:

  • It may be too simplistic for management of certain types of pain, especially neuropathic pain or other forms of chronic pain
  • The emphasis, in the lower stages, is on analgesics which are taken orally, which may occasionally be inappropriate
  • The evidence base for the efficacy of "weak" opioids (such as codeine, dihydrocodeine and tramadol) is poor. This has also resulted in historically an emphasis on pain control without full information on relative safety which is likely to rapidly change given recent epidemiological evidence that opioid use in non-cancer pain is associated with an increased all cause mortality and fracture risk compared to NSAIDs[1]
  • Certain pain management techniques, such as regional or neuraxial blocks, do not fit well into the "ladder" concept

Overall, however, the concept of the analgesic ladder is robust and useful, particularly for junior or inexperienced practitioners, and its principles underlie good pain management in many situations.

The "ladder" may equally well be conceptualised as stairs or a pyramid.


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