A modern analgesics pain 'pyramid'

J Clin Pharm Ther. 2014 Feb;39(1):4-6. doi: 10.1111/jcpt.12110. Epub 2013 Nov 19.


What is known and objective: In an effort to provide guidance for the use of analgesics for pain management--while at the same time acknowledging the professional, patient and regulatory-legal concerns about the use of strong opioids--the World Health Organization (WHO) in 1986 suggested a conservative stepwise approach. In addition to the use of non-pharmacologic measures, the WHO recommended that pharmacotherapy be initiated using a non-opioid analgesic first and then progress through 'weak' opioids or analgesic combinations to 'strong' opioids if, and only if, needed. This approach gave a rationale, and a justification if necessary, for the use of opioids. This stepwise approach became widely known as the WHO analgesic 'ladder'.

Comment: Since the initial WHO guidance, there have been significant changes in the understanding of pain. It is increasingly considered a physiological process that merits and deserves independent treatment. In addition, more analgesic options are available now than in 1986.

What is new and conclusion: Because of the evolving understanding of the physiology of pain and better approaches to its management, we suggest that more modern best practice is an analgesic 'pyramid'.

Keywords: guideline; pain management; treatment algorithm; world health organization analgesic ladder.

MeSH terms

  • Analgesics / therapeutic use*
  • Analgesics, Opioid / therapeutic use
  • Humans
  • Pain / drug therapy*
  • Pain Measurement / methods
  • World Health Organization


  • Analgesics
  • Analgesics, Opioid