The pain ladder is a term originally coined by the World Health Organization

World Health Organization

The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

 (WHO) to describe a method of controlling pain. It was originally described for the management of cancer pain

Cancer pain

Pain is a symptom frequently associated with cancer. Cancer can cause pain by irritating or damaging nerves, by stimulating nociceptors , or by releasing chemicals that make nociceptors respond to normally non-painful stimuli. Cancer pain may be caused by the tumor itself or by medical...

, but is now widely used by medical professionals for the management of all types of pain

Pain

Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...

.

The general principle in pain management is to start at the bottom rung of the ladder, and then to climb the ladder if pain is still present. The medications range from household, over-the-counter drugs with minimal side-effects at the lowest rung to powerful opioids.

The Ladder

Bottom rung of ladder (mild pain): Non opioid +/- adjuvant

Adjuvant

An adjuvant is a pharmacological or immunological agent that modifies the effect of other agents, such as a drug or vaccine, while having few if any direct effects when given by itself...

Middle rung of ladder (moderate pain): Weak opioid (Codeine

Codeine

Codeine or 3-methylmorphine is an opiate used for its analgesic, antitussive, and antidiarrheal properties...

) +/- non opioid +/- adjuvant

Highest rung of ladder (severe pain): Strong opioid (Morphine

Morphine

Morphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...

) +/- non opioid +/- adjuvant

Definitions

1. Non opioid: e.g. paracetamol

Paracetamol

Paracetamol INN , or acetaminophen USAN , is a widely used over-the-counter analgesic and antipyretic . It is commonly used for the relief of headaches and other minor aches and pains and is a major ingredient in numerous cold and flu remedies...

 (acetaminophen) OR non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin

Aspirin

Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...

, diclofenac

Diclofenac

Diclofenac is a non-steroidal anti-inflammatory drug taken to reduce inflammation and as an analgesic reducing pain in certain conditions....

, ibuprofen

Ibuprofen

Ibuprofen is a nonsteroidal anti-inflammatory drug used for relief of symptoms of arthritis, fever, as an analgesic , especially where there is an inflammatory component, and dysmenorrhea....

 

2. Weaker opioid: tramadol

Tramadol

Tramadol hydrochloride is a centrally acting synthetic opioid analgesic used in treating moderate pain. The drug has a wide range of applications, including treatment for restless legs syndrome and fibromyalgia...

, codeine

Codeine

Codeine or 3-methylmorphine is an opiate used for its analgesic, antitussive, and antidiarrheal properties...

, dihydrocodeine

Dihydrocodeine

Dihydrocodeine, also called DHC, Drocode, Paracodeine and Parzone and known by the brand names of Synalgos DC, Panlor DC, Panlor SS, Contugesic, New Bron Solution-ACE, Huscode, Drocode, Paracodin, Codidol, Didor Continus, Dicogesic, Codhydrine, Dekacodin, DH-Codeine,...

3. Strong opioid: morphine

Morphine

Morphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...

, diamorphine (heroin), fentanyl, buprenorphine

Buprenorphine

Buprenorphine is a semi-synthetic opioid that is used...

, oxymorphone

Oxymorphone

Oxymorphone or 14-Hydroxydihydromorphinone is a powerful semi-synthetic opioid analgesic first developed in Germany circa 1914, patented in the USA by Endo Pharmaceuticals in 1955 and introduced to the United States market in January 1959 and other countries around the same time...

, oxycodone

Oxycodone

Oxycodone is an opioid analgesic medication synthesized from opium-derived thebaine. It was developed in 1916 in Germany, as one of several new semi-synthetic opioids in an attempt to improve on the existing opioids: morphine, diacetylmorphine , and codeine.Oxycodone oral medications are generally...

, hydromorphone

Hydromorphone

Hydromorphone, a more common synonym for dihydromorphinone, commonly a hydrochloride is a very potent centrally-acting analgesic drug of the opioid class. It is a derivative of morphine, to be specific, a hydrogenated ketone thereof and, therefore, a semi-synthetic drug...

4. Adjuvant

Adjuvant

An adjuvant is a pharmacological or immunological agent that modifies the effect of other agents, such as a drug or vaccine, while having few if any direct effects when given by itself...

: antidepressants, anticonvulsants, steroids, muscle relaxants, exercise, psychological support, hydrotherapy

Hydrotherapy

Hydrotherapy, formerly called hydropathy, involves the use of water for pain-relief and treating illness. The term hydrotherapy itself is synonymous with the term water cure as it was originally marketed by practitioners and promoters in the 19th century...

, acupuncture

Acupuncture

Acupuncture is a type of alternative medicine that treats patients by insertion and manipulation of solid, generally thin needles in the body....