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PPM’s Editorial Board Weighs In on WHO Ladder

Agree: WHO Needs Updating

Elmer G. Pinzon, MD, MPH

Knoxville, Tennessee

I agree that the outdated WHO pain ladder diagram (1986), although very beneficial in its day, is in need of some modifications, as proposed by Drs. Pergolizzi and Raffa. Since chronic pain syndrome is a complex problem with medical and psychosocial aspects, it requires a comprehensive and multidisciplinary approach to evaluation and treatment. I agree that the use of fixed-dosed and long-term medications should be expanded (and reflected) in the WHO pain ladder. Given the benefits of interventional pain-relieving procedures in modern practical pain management, I also would strongly encourage the use of interventional pain procedures (ie, nerve blocks, neuroablation, neuromodulation, etc.) as an expanded rung on the WHO pain ladder. Overall, I welcome and commend the authors on this well-written, concise article on the discussion of potential modifications to the WHO pain ladder. 

Gordon D. Ko, MD

University of Toronto, Ontario

I am in general agreement with this editorial. I would add that there should be mention of adjuvant medications that enhance opioid effectiveness, eg, cannabinoids such as nabilone (Cesamet; Sativex oral spray-approved in Canada). This is timely because an increasing number of states are allowing the use of medical marijuana.

For interventional treatments, I would also include botulinum toxin, particularly Botox (onabotulinum toxin), which is FDA approved for the management of chronic migraine. In addition, several randomized controlled trials have shown that onabotulinum toxin is effective for neuropathic pain, a common complication of cancer and chemotherapy.

Kern A. Olson, PhD

Beaverton, Oregon

As a non-prescribing pain provider, I would like to weigh in on this discussion to give it more perspective. First, the WHO ladder is only a guide, and it is outdated, given that there are many newer pain medicines that were not around in 1986. One example given by the authors is buprenorphine: What rung of the WHO ladder would this medicine fall—Level 2 or 3, or in a separate level?  

In my opinion, the intention of the ladder remains valid. It makes sound clinical sense to start with the appropriate size hammer before you bring out the big one! As a practicing pain psychologist, I also think it makes sound clinical sense to require a multidisciplinary treatment plan before you move on to Level 3 opioids in the long-term management of non-cancer pain. This recommendation would include a psychosocial evaluation, which also makes sound clinical sense since the prescribing provider should want to know what they are getting into before they initiate a long-term treatment plan.

With respect to breakthrough pain, Bill Fordyce addressed this issue by introducing the “pain cocktail” at the University of Washington pain program. He believed in a fixed-dose schedule to avoid reinforcing pain behavior. From a conditioning perspective, if you prescribe a short-acting Level 2 opioid for breakthrough pain you are, in fact, reinforcing the pain behavior that usually results in more demand for short-acting opioids. Breakthrough pain is a very complex issue because it involves a number of factors, including depression. Does the provider want to treat clinical depression with centrally acting medicines that depress the central nervous system? After 25 years of experience as a pain psychologist, I have learned that breakthrough pain usually is the result of the patient not listening to his or her body and pushing the limits of physical activity.

Proceed With Caution

Joseph Shurman, MD

La Jolla, California

I think if you are going to suggest changes to the WHO pain ladder, you need be very cautious. This should be backed by evidence-based guidelines, for example the American Pain Society guidelines on opioids and the American Society of Interventional Pain Physicians spine intervention guidelines.1,2 Unfortunately, in all modes of pain management, we need better and longer-term studies. During the Physicians for Responsible Opioid Prescribing (PROP) debate on opioid prescribing, the Food and Drug Administration recommended long-term studies on opioids for the treatment of severe non- malignant pain (eg, measuring function, quality of life, pain relief, and risk of addiction).3 Sean Mackey, MD of Stanford University has lectured on this very point, and I agree with him.

In addition, there is the controversy over interventional procedures—including the denial of many interventional procedures by the State of Washington’s Workers Compensation board. Our specialty has been around for less then one generation and continues to evolve.

First, Do No Harm

Leonard B. Goldstein, DDS, PhD

Old Westbury, New York

It is my opinion, while Pergolizzi and Raffa present a compelling presentation for a modification of the WHO pain ladder, I believe that it is incumbent on all providers of pain management to individualize the pain ladder to take specific patient requirements into consideration. Some patients (including some terminal cancer patients) will respond well to therapies that include less use of opioids, and greater use of therapies such as osteopathic manipulation, acupuncture and traditional oriental medicine, etc.

Let us all strive to eliminate pain, while realizing the potential harm of some of our treatments.  First, Do No Harm!


Last updated on: May 30, 2014
First published on: February 1, 2014