Template 4

The World Health Organization (WHO) analgesic ladder consists of a hierarchy of oral pharmacologic interventions designed to effectively treat pain of increasing magnitude. The ladder presents a framework for the rational use of oral medication before application of other techniques of drug administration. Opioid therapy is considered the mainstay approach for patients with moderate or severe pain. The type of medication administered is sequentially escalated from nonopioids (e.g., nonsteroidal antiinflammatory drugs (NSAIDs) <pm> adjuvants to opioids used for mild to moderate pain (codeine, dihydrocodeine, oxycodone (compounded with a coanalgesic), hydrocodone, dihydrocodone) <pm> adjuvants to opioids commonly used for severe pain (morphine, hydromorphone, methadone, oxycodone (without compounding), fentanyl or levorphanol). Adjuvant medications are listed in template 7. (Modified with permission from WHO: Cancer pain relief and palliative care: Report of a WHO expert committee. Geneva, World Health Organization, 1990 (technical report series, no. 804).)