The WHO analgesic ladder for cancer pain management recommends a stepwise approach. A patient with cancer pain not controlled on non-opioids (Step 1) should be escalated to Step 2, which includes:

• A Strong opioids (morphine, oxycodone) with or without non-opioids
• B Adjuvant drugs alone (gabapentin, amitriptyline)
• C Invasive procedures (nerve blocks, intrathecal opioids)
• D Weak opioids (codeine, tramadol) with or without non-opioids ✓

Explanation

The WHO three-step analgesic ladder: Step 1 — non-opioids (paracetamol, NSAIDs) ± adjuvants; Step 2 — weak opioids (codeine, tramadol, dihydrocodeine) ± non-opioids ± adjuvants; Step 3 — strong opioids (morphine, oxycodone, fentanyl, hydromorphone) ± non-opioids ± adjuvants. Adjuvants (antidepressants, anticonvulsants, steroids) can be added at any step to address neuropathic, inflammatory, or bone pain components. When Step 2 fails to control pain, escalation to Step 3 strong opioids is indicated. The ladder emphasises oral route, regular dosing ('by the clock'), and individual titration.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.