The World Health Organization (WHO) Pain Ladder is a globally recognized framework for the systematic management of pain, particularly in palliative care and oncology settings. Introduced in 1986, it offers a three-step approach that aligns the intensity of analgesic therapy with the severity of the patient's pain. This simple yet effective strategy has since become a cornerstone of pain relief protocols worldwide.

• Step 1 involves the use of non-opioid analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) for mild pain.

• Step 2 recommends the addition of weak opioids like codeine or tramadol when pain persists or increases.

• Step 3 addresses severe pain through the use of strong opioids such as morphine, often in combination with non-opioids and adjuvant therapies to enhance efficacy and manage associated symptoms (Suh et al., 2011; Coluzzi et al., 2016).

Step	Type of Pain	Treatment Approach	Example Medicines
1️⃣	Mild Pain	✅ Non-opioid ± Adjuvant	- Paracetamol (acetaminophen) - Ibuprofen (NSAIDs)
2️⃣	Moderate Pain	✅ Weak opioid + Non-opioid ± Adjuvant	- Codeine - Tramadol + Paracetamol
3️⃣	Severe Pain	✅ Strong opioid ± Non-opioid ± Adjuvant	- Morphine - Fentanyl - Oxycodone

A robust body of evidence supports the clinical effectiveness of this ladder. For example, adherence to its principles has been shown to relieve cancer-related pain in approximately 70% to 90% of cases (Suh et al., 2011; Choudhury et al., 2018). Furthermore, it provides a foundational structure that is adaptable to diverse patient populations, including those with chronic illnesses or postoperative needs (Watson et al., 2021; Mishra et al., 2007).

Recent adaptations of the WHO Pain Ladder reflect growing knowledge in pain science and evolving healthcare demands. These modifications aim to enhance flexibility and individualization in pain management strategies—highlighting the ladder's enduring relevance and capacity for refinement (Raffa & Pergolizzi, 2013; Coluzzi et al., 2016).

While the WHO Pain Ladder is widely used and has improved pain management, especially in cancer care, barriers such as regulatory restrictions and insufficient clinician training hinder optimal opioid use. Additionally, conditions like neuropathic pain often require multidisciplinary strategies beyond the traditional ladder. To ensure effective and individualized pain relief, ongoing education, research, and policy changes are essential.

• Bautista, C., Amatangelo, M., Baby, P., Cassier-Woidasky, A., Dycus, K., Edoh, E., … & Wessol, J. (2021). Cultural perspectives on pain assessment and opioid use: International neuroscience nursing research symposium conference proceedings. Journal of Neuroscience Nursing, 53(3), 149–156. https://doi.org/10.1097/jnn.0000000000000585

• Choudhury, K., Dasgupta, P., Paul, N., Choudhury, K., Roy, B., & Maity, S. (2018). A comparative study of transdermal buprenorphine and oral morphine in the treatment of chronic pain of malignant origin. Indian Journal of Palliative Care, 24(4), 500. https://doi.org/10.4103/ijpc.ijpc_83_18

• Coluzzi, F., Taylor, R., Pergolizzi, J., Mattia, C., & Raffa, R. (2016). Good clinical practice guide for opioids in pain management: The three Ts – Titration (trial), Tweaking (tailoring), Transition (tapering). Brazilian Journal of Anesthesiology (English Edition), 66(3), 310–317. https://doi.org/10.1016/j.bjane.2014.09.005

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• Heer, E., Dekker, J., Beekman, A., van Marwijk, H., Holwerda, T., Bet, P., … & van Feltz‐Cornelis, C. (2018). Comparative effect of collaborative care, pain medication, and duloxetine in the treatment of major depressive disorder and comorbid (sub)chronic pain: Results of an exploratory randomized, placebo-controlled, multicenter trial (CC:PAINDIP). Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00118

• Javier, F., & Calimag, M. (2007). Opioid use in the Philippines — 20 years after the introduction of the WHO analgesic ladder. European Journal of Pain Supplements, 1(S1), 19–22. https://doi.org/10.1016/s1754-3207(08)60007-3

• Mishra, S., Bhatnagar, S., Gupta, D., & Diwedi, A. (2007). Incidence and management of phantom limb pain according to World Health Organization analgesic ladder in amputees of malignant origin. American Journal of Hospice and Palliative Medicine®, 24(6), 455–462. https://doi.org/10.1177/1049909107304558

• Raffa, R., & Pergolizzi, J. (2013). A modern analgesics pain ‘pyramid’. Journal of Clinical Pharmacy and Therapeutics, 39(1), 4–6. https://doi.org/10.1111/jcpt.12110

• Suh, S., Song, K., Choi, S., Ahn, H., Choi, Y., & Shim, J. (2011). Factors related to substantial pain in terminally ill cancer patients. The Korean Journal of Hospice and Palliative Care, 14(4), 197–203. https://doi.org/10.14475/kjhpc.2011.14.4.197

• Watson, C., Jafri, S., Cobain, C., & Menon, G. (2021). Severe pain in a leiomyoma with twin pregnancy – An analgesic dilemma. Pain Management Case Reports, 247–250. https://doi.org/10.36076/pmcr.2021.5.247