The analgesic ladder is a concept developed by the World Health Organization (WHO) in the 1980s, initially for the management of cancer pain and later for handling all types of pain. Under this concept, doctors follow a stepped approach with pain management to reach the goal of eliminating pain with the lowest possible pain control. This can reduce the risk of side effects for the patient and also means that more aggressive pain control will be effective and available when needed because the patient has not developed a tolerance.
The first step in the analgesic ladder is the use of a non-opioid medication, possibly with an adjuvant. Drugs like aspirin fall into this category, while patients might also take medications to manage seizures, control depression, or handle other symptoms they experience. The addition of an adjuvant can mean that the patient avoids using pain control when she really needs a different medication.
If the patient still experiences pain, it is time to move to the next step, the use of a weak opioid with an adjuvant if appropriate. The patient might benefit from a pain management drug like codeine along with another medication to manage inflammation or other sources of discomfort. If pain levels continue at this stage, the patient reaches the top of the analgesic ladder, where a doctor can prescribe a strong opioid such as fentanyl along with an appropriate adjuvant.
Pain is a complicated condition to manage and there are a number of approaches to pain relief. Tools like the analgesic ladder create a clear set of criteria for managing pain to make it easier for doctors to determine what the next stage should be. At each step, a doctor can make decisions like adjusting dosages, trying different medications, or exploring additional adjuvants to see if these will bring the patient's pain under control. Treatments like psychotherapy or electrical nerve stimulation for pain, for example, may be more beneficial for a patient than ramping up analgesic dosages.
Patients with chronic pain conditions can be difficult to treat accurately and effectively, even with the analgesic ladder. With many opioids, there is the concern of acquiring resistance over time. The patient will need increasingly high doses of medication to control pain, and may eventually find a pain management technique ineffective. A pain specialist may be able to offer the best treatment, in contrast with a general practitioner or a doctor who focuses on another area of medical care like rheumatology.