According to the WHO analgesic ladder for cancer pain, what is the CORRECT sequence and principle of opioid escalation?

• A Step 1: Weak opioid (codeine/tramadol) → Step 2: Strong opioid (morphine) → Step 3: Invasive procedures; all steps require adjuvants
• B Step 1: NSAID → Step 2: Tramadol → Step 3: Fentanyl patch; no adjuvants recommended
• C Step 1: Non-opioid ± adjuvant → Step 2: Weak opioid + non-opioid ± adjuvant → Step 3: Strong opioid + non-opioid ± adjuvant ✓
• D Step 1: Strong opioid → Step 2: Nerve block → Step 3: Palliative sedation

Explanation

The WHO 3-step analgesic ladder (1986, revised): Step 1 — non-opioid (paracetamol/NSAID) ± adjuvant for mild pain; Step 2 — add weak opioid (codeine, tramadol) + non-opioid ± adjuvant for moderate pain; Step 3 — replace with strong opioid (morphine, oxycodone, fentanyl) + non-opioid ± adjuvant for severe pain. Adjuvants (antidepressants, anticonvulsants, corticosteroids, bisphosphonates) are added at any step for specific pain types. The principle is 'by the mouth, by the clock, by the ladder'; a 4th step (interventional) is sometimes added.

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

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