Cancer pain – WHO ladder


The World Health Organization has developed a 3-step ladder for pain management in adult cancer patients. This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. The three steps are as follows: Step 1: Non-opioid analgesics such as ASA, NSAIDs, acetaminophen (+/- adjuvants) for mild pain. If pain persists/increases, proceed to step 2. Step 2:“Weak” opioid such as codeine or oxycodone (+/- non-opioids and adjuvants) for moderate pain. If pain persists/increases, proceed to step 3. Step 3: Stronger opioids such as morphine or dilaudid (+/- non-opioids and adjuvants) for severe pain.  Keys to remember:

  • The Oral route is preferred for all steps of pain ladder (however, parenteral therapy may be required in cases of refractory pain or inability to take P.O.)
  • Cancer pain is continuous. Analgesics should be scheduled at regular intervals as opposed to on a PRN basis.
  • Adjuvant drug therapy is used to decrease the anxiety and fear associated with chronic pain. These adjuvants include antidepressants, anticonvulsants, etc.


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WHO analgesic ladder