What Is the Pain Ladder?

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  • Written By: Meshell Powell
  • Edited By: Melissa Wiley
  • Last Modified Date: 06 November 2018
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The pain ladder is a guide that was originally developed by the World Health Organization to instruct doctors and other medical professionals on the safest and most effective ways to treat pain caused by cancer. The use of this pain ladder is now routinely implemented as a tool to treat many types of chronic pain. The basic guidelines involve using the lowest possible medication strengths and dosages, moving to stronger drugs as necessary. If significant levels of pain are still present after reaching the top of the pain ladder, surgical intervention may sometimes be employed.

The first step on the pain ladder involves the use of non-opioid medications plus an adjuvant. Non-opioid medications include over-the-counter pain relievers such as aspirin, acetaminophen, or ibuprofen. An adjuvant is a medication that has not been specifically designed to treat pain but has been shown to be helpful in treating some pain conditions, especially when combined with other drugs. Antidepressants, anticonvulsants, and muscle relaxants are frequently used as adjuvant medications.

If pain levels are not able to be brought under control with over-the-counter and adjuvant medications, the second step on the pain ladder may be implemented. Mild opioid medications such as codeine are often used at this stage and combined with non-opioid drugs as well as adjuvant medications. Many pain issues are able to be successfully treated with this combination of drugs, although the exact medications and dosages may be adjusted according to individual needs.


The third and final step on the pain ladder involves the replacement of medications such as codeine with stronger opioid drugs, including oxycodone or morphine. The non-opioid medications and adjuvant drugs continue to be used at this stage, although dosage adjustments are frequently required. This drug combination is used to treat severe pain that has not been relieved by more conservative means. Stronger pain medications also lead to a greater risk of side effects, such as dizziness or drowsiness, so care should be taken when performing activities that require high levels of focus or concentration.

In most cases, the use of the pain ladder successfully treats chronic pain issues. Occasionally, a person will still experience pain that is severe enough to disrupt daily life. When this occurs, surgical intervention may become necessary in order to make the patient more comfortable. Depending on the individual situation, nerves may be severed or implantable devices may be used in an effort to reduce or eliminate pain. The supervising physician can help the patient decide on the best treatment plan in an individual situation.



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