Write a short note on WHO Analgesic Ladder.

Definition

The WHO analgesic ladder is a stepwise framework for matching analgesia to pain severity. Originally devised for cancer pain, it is widely applied to acute and chronic pain and provides a simple, logical approach to escalating (or de-escalating) analgesia.

The Three Steps

Step 1 (mild pain):

• non-opioids — paracetamol and/or an NSAID — ± an adjuvant.
• Step 2 (moderate pain): a weak opioid (codeine, tramadol) added to the non-opioid ± adjuvant.
• Step 3 (severe pain): a strong opioid (morphine) with the non-opioid ± adjuvant. One climbs the ladder as pain increases
• for acute postoperative pain it is often used in reverse (starting at the top and stepping down as pain settles).

Practical Use in Acute Pain

Although the ladder was designed to be climbed as chronic cancer pain worsens, in the setting of acute postoperative pain it is most useful when applied in reverse: the pain is usually most severe immediately after surgery and then steadily improves, so treatment starts at the top with strong opioids combined with regular non-opioids and is stepped down to weak opioids and then non-opioids alone as recovery proceeds. Throughout, the non-opioid base of paracetamol and, where appropriate, an anti-inflammatory is maintained, providing continuous background analgesia and reducing the opioid requirement, and adjuvants are added for any neuropathic component.

In Brief

In short, it is the same three steps run downwards after surgery, with the non-opioid base never abandoned.

Originally for cancer pain; now applied to acute pain in reverse.

• WHO ladder matches analgesia to severity (originally cancer pain, widely applied).
• Step 1 non-opioids ± adjuvant → Step 2 weak opioid + non-opioid → Step 3 strong opioid + non-opioid.
• Adjuvants at any step; keep the non-opioid base throughout (opioid-sparing).
• Acute postoperative pain often uses the ladder in reverse.