Back to Journals » Journal of Pain Research » Volume 13

The Modified WHO Analgesic Ladder: Is It Appropriate for Chronic Non-Cancer Pain?

Authors Yang J, Bauer BA, Wahner-Roedler DL, Chon TY, Xiao L

Received 2 January 2020

Accepted for publication 30 January 2020

Published 17 February 2020 Volume 2020:13 Pages 411—417


Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 2

Editor who approved publication: Dr Michael E Schatman

Juan Yang,1,2 Brent A Bauer,2 Dietlind L Wahner-Roedler,2 Tony Y Chon,2 Lizu Xiao1

1Department of Pain Medicine, Shenzhen Nanshan People’s Hospital, Shenzhen 518052, People’s Republic of China; 2Division of General Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA

Correspondence: Lizu Xiao
Department of Pain Medicine, Shenzhen Nanshan People’s Hospital, NO. 89, Taoyuan Avenue, Nanshan District, Shenzhen 518052, People’s Republic of China
Tel +86 755-26553111

Introduction: From 1986, the World Health Organization (WHO) analgesic ladder has been used as the simple and valuable pain-relieving guidance in the pharmaceutical pain management, however, with the development of medical history, notions about pain physiology and pain management have already updated. Is the analgesic ladder still appropriate for chronic non-cancer pain (CNCP) patients? This study aims to analyse the current usage of the analgesic ladder in patients with CNCP by evaluating previously published pertinent studies.
Methods: Literature published in English from January 1980 to April 2019 and cited on PubMed database was included. Analysis on the analgesic ladder, current status of CNCP management, and a new revised ladder model were developed based on relevant literature.
Results: The WHO analgesic ladder for cancer pain is not appropriate for current CNCP management. It is revised into a four-step ladder: the integrative therapies being adopted at each step for reducing or even stopping the use of opioid analgesics; interventional therapies being considered as step 3 before upgrading to strong opioids if non-opioids and weak opioids failed in CNCP management.
Discussion: A simple and valuable guideline in past years, the WHO analgesic ladder is inappropriate for the current use of CNCP control. A revised four-step analgesic ladder aligned with integrative medicine principles and minimally invasive interventions is recommended for control of CNCP.

Keywords: analgesic ladder, chronic pain, chronic non-cancer pain, opioid, pain management

Creative Commons License This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.

Download Article [PDF]  View Full Text [HTML][Machine readable]