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. 2020 Feb 17:13:411-417.
doi: 10.2147/JPR.S244173. eCollection 2020.

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

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

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

Juan Yang et al. J Pain Res. .

Abstract

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 non-cancer pain; chronic pain; opioid; pain management.

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Conflict of interest statement

The authors have indicated that they have no conflicts of interest with regard to the content of this article.

Figures

Figure 1
Figure 1
A generalized representation of a four-step analgesics ladder. Such four-step ladder, as opposed to the 1986 “ladder”, reflects the advances in nonopioid modalities application for better pain relieving. The integrative medicine therapies can be adopted in each step for reducing or even stopping the use of analgesics to all types of pains. If the non-opioids and weak opioids failed, minimally invasive interventions in step 3 can be recommended before upgrading to strong opioids.
See this image and copyright information in PMC

References

    1. Rudd RA, Aleshire N, Zibbell JE, Matthew Gladden R. Increases in drug and opioid overdose deaths—United States, 2000–2014. Am J Transplant. 2016;16(4):1323–1327. doi:10.1111/ajt.13776 - DOI - PubMed
    1. Makary MA, Overton HN, Wang P. Overprescribing is major contributor to opioid crisis. BMJ (Clinical Research Ed). 2017;359:j4792. doi:10.1136/bmj.j4792 - DOI - PubMed
    1. Vadivelu N, Kai AM, Kodumudi V, Sramcik J, Kaye AD. The opioid crisis: a comprehensive overview. Curr Pain Headache Rep. 2018;22(3):16. doi:10.1007/s11916-018-0670-z - DOI - PubMed
    1. Häuser W, Schug S, Furlan AD. The opioid epidemic and national guidelines for opioid therapy for chronic noncancer pain: a perspective from different continents. Pain Rep. 2017;2:3. doi:10.1097/PR9.0000000000000599 - DOI - PMC - PubMed
    1. Merskey HE. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Pain. 1986. - PubMed