The WHO ladder – cornerstone of the WHO guidelines on Cancer Pain therapy

In its guidelines on cancer pain therapy, the World Health Organization  (WHO) presented general principles for the management of pain in cancer patients, emphasizing the importance of drug therapy: "Drug treatment is the mainstay of cancer pain management".1-4

The five principles for the use of analgesics in cancer pain therapy are of fundamental significance and still form the basis of cancer pain treatment:

  • "by mouth"
  • "by the clock"
  • "by the ladder"
  • "for the individual"
  • "attention to detail"

The principle behind the WHO ladder is that treatment decisions are guided by pain severity.

In step I for moderate pain a non-opioid analgesic such as paracetamol, dipyrone or an NSAID is prescribed. If necessary, adjuvants (co-analgesics) may be added. If analgesia is unsatisfactory (pain persists or increases), a weak opioid such as tramadol may be added in step II, then the switch to a strong opioid such as morphine is recommended in step III. When going to the next step, the non-opioids and co-analgesics should be continued whenever possible. Patients with severe pain could be treated directly with strong opioids.

It is also very important, however, to consider the underlying pathology and mechanism of pain in the individual patient in order to provide optimal effective pain treatment to patients with cancer.



1 WHO. 2007.
2 Cancer pain relief and palliative care, Report of a WHO Expert Committee. Geneva: WHO, 1990. 75 p. ISBN: 9789241208048. Available from:
3 Cancer pain relief, With a guide to opioid availability. 2nd ed. Geneva: World Health Organization, 1996. vi, 63. ISBN: 9789241544825. Available from:
4 Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain 1995;63:65–76. eng.