The pain ladder is a term originally coined by the World Health Organization (WHO) to describe a method of controlling pain.[1] It was originally described for the management of cancer pain, but is now widely used by medical professionals for the management of all types of pain.
The general principle in pain management is to start at the bottom rung of the ladder, and then to climb the ladder if pain is still present. The medications range from household, over-the-counter drugs with minimal side-effects at the lowest rung to powerful opioids.
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Bottom rung of ladder (mild pain): Non opioid +/- adjuvant
Middle rung of ladder (moderate pain): Weak opioid (Codeine) +/- non opioid +/- adjuvant
Highest rung of ladder (severe pain): Strong opioid (Morphine) +/- non opioid +/- adjuvant
1. Non opioid: e.g. paracetamol (acetaminophen) OR non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, diclofenac, ibuprofen
2. Weaker opioid: tramadol, codeine, dihydrocodeine
3. Strong opioid: morphine, diamorphine (heroin), fentanyl, buprenorphine, oxymorphone, oxycodone, hydromorphone
4. Adjuvant: antidepressants, anticonvulsants, steroids, muscle relaxants, exercise, psychological support, hydrotherapy, acupuncture