WHO Analgesic Ladder

This article discusses the WHO analgesic ladder and describes its relevance to acute pain management and is useful if you manage people in pain on a regular basis.

Learning outcomes:

  1. to understand the basis of the WHO analgesic ladder
  2. to understand the concept of multimodal analgesia

WHO Analgesic Ladder

An analgesic  is a member of the group of drugs which are used to relieve pain, also known as “painkillers”. The word analgesic derives from Greek an ("without") and algos ("pain").

The analgesic ladder was designed by the World Health Organisation (WHO) [1] as a conceptual framework to assist in the prescription of analgesic drugs. The ladder was initially introduced to improve the pain control of patients with cancer pain, however, it has lessons for the management of acute pain as it employs a logical strategy to manage pain. Hence today, it forms the basis of managing pain in the clinical environment.

The ladder advocates a stepped approach to the use of painkillers from these analgesic groups:

  • Non-opioid analgesics i.e. paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs)
  • Weak opioids i.e. tramadol, codeine
  • Strong opioids i.e. morphine, fentanyl, oxycodone, pethidine
  • Adjuvants - adjuvant analgesics are drugs which were not originally for pain but rather for other conditions but have been found to be effective in difficult to manage pain, particularly neuropathic pain. They are a diverse group of drugs that includes antidepressants, anticonvulsants (antiseizure drugs), and others.

At every step of the analgesic ladder non-opioid analgesics form the basis of the pain management. Paracetamol and NSAID (if not contraindicated) should always therefore be prescribed with opioid analgesia (weak or strong). This is known as multi-modal analgesia and is the concept that pain is best managed, not by a single drug or therapy, but by combinations, which maximise efficacy whilst keeping side-effects low. Evidence has demonstrated that when this happens pain relief is better, smaller amounts of pain killers are needed and less side effects occur. The combination of paracetamol and NSAIDS with opioids has been shown to reduce the amount of opioids required to achieve the same effect by 20-30% [2].


WHO Analgesic Ladder

Figure 1: WHO Analgesic Ladder

The WHO advocates that these analgesics should be given “by the clock”, that is every 3-6 hours, rather than “on demand.” This stepped approach of administering the right drug in the right dose at the right time is inexpensive and generally effective in managing acute pain.

The advantages of the analgesic ladder include:

  • Simplicity, in that only a few, widely-known drugs are used
  • Applicability to a large variety of pain situations and also to prescribers globally
  • Safety, in that safest drugs are used first in their lowest effective dose
  • Emphasis on multimodal analgesia.

Its disadvantages include:

  • It may be too simplistic for management of certain types of pain, especially neuropathic pain or for those who are opioid dependant.
  • It suggests that analgesics should be administrated orally, which may occasionally not be appropriate, for example, post-operatively when patients are 'nil by mouth'.



Visitors registering with their Healthcare Professional details gain access to a private peer2peer discussion forum. The most active topics in the peer2peer forum will appear here.

My bookmarks

Registered visitors can bookmark any content for later reading. Audio/Video presentations are then also available as a personal podcast that can be added to your mp3 player to watch offline.
Click the "Bookmark this" link when viewing a piece of content to add it to this list.