Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Management of Pain:The Analgesic Ladder

The WHO analgesic ladder is intended to be a guideline in structuring the use of analgesia in the pharmacological management of pain, and is not intended to be a rigid framework. The WHO approach to pain control may need to be combined with other treatment modalities. Evaluate the type and intensity of the pain, and then match the drug to the pain intensity and other characteristics.

The use of analgesia should start at the step of the analgesic ladder appropriate for the severity of pain. It is not necessary to initiate therapy at Step 1 if the person is experiencing moderate to severe pain, patients with severe pain should have therapy initiated at Step 3.

The use of the ladder is reversed in situations of acute pain, starting at Step 3 and moving to Step 1 analgesics as recovery occurs.

This figure shows a simple plan for acute pain management, which is an adaptation of the WHO Analgesic Ladder. As acute pain decreases, weaker analgesics are used.


Reprinted with permission of the World Health Organization.