• guideline;
  • pain management;
  • treatment algorithm;
  • world health organization analgesic ladder


What is known and objective

In an effort to provide guidance for the use of analgesics for pain management – while at the same time acknowledging the professional, patient and regulatory–legal concerns about the use of strong opioids – the World Health Organization (WHO) in 1986 suggested a conservative stepwise approach. In addition to the use of non-pharmacologic measures, the WHO recommended that pharmacotherapy be initiated using a non-opioid analgesic first and then progress through ‘weak’ opioids or analgesic combinations to ‘strong’ opioids if, and only if, needed. This approach gave a rationale, and a justification if necessary, for the use of opioids. This stepwise approach became widely known as the WHO analgesic ‘ladder’.


Since the initial WHO guidance, there have been significant changes in the understanding of pain. It is increasingly considered a physiological process that merits and deserves independent treatment. In addition, more analgesic options are available now than in 1986.

What is new and conclusion

Because of the evolving understanding of the physiology of pain and better approaches to its management, we suggest that more modern best practice is an analgesic ‘pyramid’.