Intended for healthcare professionals


WHO analgesic ladder: a good concept gone astray

BMJ 2016; 352 doi: (Published 06 January 2016) Cite this as: BMJ 2016;352:i20
  1. Jane C Ballantyne, professor of anesthesiology and pain medicine1,
  2. Eija Kalso, professor of pain medicine2,
  3. Cathy Stannard, consultant in pain medicine3
  1. 1Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
  2. 2Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
  3. 3Pain Clinic, Southmead Hospital, Bristol, UK
  1. Correspondence to: J C Ballantyne jcb12{at}

Our mistake is to treat chronic pain as if it were acute or end of life pain

In 1986, the World Health Organization (WHO) developed a simple model for the slow introduction and upward titration of analgesics, which became known as the WHO analgesic stepladder.1 Before this, people were dying in unnecessary pain because drug regulations introduced earlier in the century had increased the stigma and fear associated with both prescribing and taking opioids.

The underlying principle was that analgesics should be used incrementally, starting with non-opioids, progressing through mild and finally strong opioids, dosed in accordance with the patient’s reported pain intensity. It was expected that opioids would be needed in increasing doses to overcome pain as cancer progressed. The goal was to allow patients to be as comfortable and interactive as possible during the short march towards death. Risks of addiction and hastened death were accepted in the principle of double effect: comfort is paramount.2

The stepladder approach had tremendous value when it was introduced because it legitimised the use of opioids, overcoming prejudicial …

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