Editor's Memo: The WHO Pain Treatment 3-Step Ladder
A few days ago, I gave a lecture to a group of pain practitioners composed of physicians, physician assistants, nurse practitioners, psychologists, and pharmacists. Less than half of the audience reported being familiar with the World Health Organization’s (WHO) 3-step ladder of pain control, which I consider the gold standard for pain management.
No wonder. In the past few years, we have seen our field bombarded with condemnations, attacks, regulations, and falsehoods. In fact, the use of opioids and epidural corticosteroid injections now is being criticized, in part because they have been promoted as first-line pain treatments. The attention given to the opioid overdose epidemic has spawned an abuse control industry that is oversaturated with rules and regulations that ignore the basis of good pain control.
To me, one development that has obscured good pain treatment perhaps more than anything else is the wide-scale promulgation of opioid treatment guidelines, laws, and regulations. Every pain organization, as well as many non-pain ones, has published its own guidelines on opioid prescribing. To the new or inexperienced pain practitioner, it may seem erroneously that all of the opioid guidelines are treatment standards. They are not. They only address 1 or 2 elements of the standard treatment template laid out in the WHO 3-step ladder (Figure 1).
The WHO 3-step ladder was devised in 1982 and officially adopted in 1986.1-6 Although almost 30 years have passed since its adoption, it remains the pain treatment standard. It is not a specific opioid guideline but a template that provides a practical roadmap for pain treatment. Its essence has endured, simply because it makes practical, clinical sense, and provides effective, humanitarian care.1-5
Over the 3 decades since its release, no organization has successfully attempted to repeal or develop an alternative to the 3-step ladder. Some parties have tried, to no avail, to modify or amend it.1,2 These attempts have not achieved any universal backing because the ladder views opioids as secondary to non-opioid measures, which are grouped into 2 categories: non-opioid pharmaceuticals and adjuvant therapies, which include non-pharmacologic measures. Fundamentally, it calls for a multifaceted approach to pain treatment in which opioids are secondary and not primary. They are not to be restricted but rather to be used when necessary.
The term adjuvant admittedly may be confusing or unclear to practitioners who were not around when the WHO ladder received extraordinary publicity.1-4 Adjuvants include such non-pharmacologic treatments as acupuncture, physical measures, electromagnetic therapies, and psychotherapy. Corticoid injections and prolotherapy have adjunctive and non-opioid pharmacologic characteristics. A key element to the WHO 3-step ladder is that opioids are to be added to, not substituted for, an existing regimen of non-opioid pharmacologic agents and adjuvants. Non-opioid medications and adjuvants can be added or switched at any step, but they must be an integral component of the treatment regimen.
In my opinion, the recent crisis in opioid prescribing that has resulted in overdoses, diversion, and dosage escalation is, at least in part, the result of ignorance about the intent and execution of the WHO 3-step ladder. For example, I have been referred many patients with cervical spine disease or injury who have undergone surgical fusion after receiving multiple epidural corticosteroid injections. When they were referred to my practice, they might have been taking 2 or more opioids, but they had not been taught cervical bracing or range of motion exercises, had not been offered electromagnetic measures, and had not been given decent trials of anti-inflammatories, topical analgesics, and neuropathic agents. Please disagree with me, but from my personal vantage point, non-opioid pharmacologic agents and non-pharmacologic adjuvants as called for in the 3-step ladder all too often are not being pursued.
Criticisms of the 3-step ladder are that medications have changed since 1986 and that the ladder is too non-specific.1-4 Thus, physicians reviewing the same patient could prescribe different treatment regimens despite using the same treatment template. A classic example of this phenomenon is the management of patients with neuropathic pain, for which some physicians use drugs (eg, anticonvulsants and anti-depressants) at Step 1 and others at Step 3.6 I argue, as have others, that the lack of specificity within the WHO template is very positive and allows physicians great leeway to provide individualized care.6
There also is debate over which of today’s opioids are weak or strong. Confusion over this issue arises to a great extent over the scheduling of opioids in the Controlled Substances Act. For example, hydrocodone-acetaminophen products recently have been moved from Schedule III to II. But does this now make these agents more potent? Buprenorphine now is available in sublingual and patch formulations. Is the patch a weak or strong opioid, considering it may last several days? I suggest that tramadol, buprenorphine, butorphanol, and opioids, such as codeine, hydrocodone, and oxycodone that are combined with acetaminophen, ibuprophen, aspirin, or other anti-inflammatory agents should be considered weak. All other commercially available opioids should be considered strong. This particularly applies to the long-acting opioid preparations. You may have a different view of weak and strong opioids, but these differences should make little practical difference if the pain treatment regimen is built on a non-opioid base, as called for in the WHO Ladder.
In summary, the WHO 3-Step Ladder still is the standard template for treatment of cancer and non-cancer chronic pain. Opioids, weak or strong, are added, not substituted, to a regimen of non-opioid pharmacologic agents and adjuvants. The WHO 3-step ladder has endured for 30 years, simply because it gives the practitioner a practical protocol to follow that allows the provision of safe, effective, individualized treatment to countless patients.
PPM For Your Patients
We are trying to spread the word to our readers that PracticalPainManagement.com, the Web site for Practical Pain Management, has a wonderful resource for patients. I invite all readers to visit our patient side, which contains basic information on a number of pain conditions and treatments, written by authors and Editorial Board Members of Practical Pain Management. This is an excellent resource for educating your patients about their disease and we encourage all readers to have their patients visit PracticalPainManagement.com/consumer to learn more.