💊 WHO Analgesic Ladder Cancer Pain Simulator

Reporting Pain — The 0–10 Numeric Rating Scale

Every ladder decision starts with the patient's own reported number.

• 0–10: Scale range (patient self-report)
• 1–3: Mild band (Step 1 territory)
• 4–6: Moderate band (Step 2 territory)
• 7–10: Severe band (Step 3 territory)

Why the score drives the step

The reported number, not the diagnosis, selects the starting step.

Reassessment cadence

Pain is re-scored regularly; the step can change either direction.

Mild Pain — Non-Opioid Analgesics ± Adjuvant

Scores of 1–3 start on acetaminophen or an NSAID.

• 1–3 / 10: Pain band (mild)
• 2: Core drugs (acetaminophen, NSAIDs)
• None: Opioid used (not indicated at this step)
• Yes: Adjuvant option (as clinically indicated)

Step 1 drug class

Non-opioid analgesics form the base of the ladder.

Adjuvant role

Adjuvants target neuropathic or bone-pain components alongside Step 1.

Moderate Pain — Weak Opioid Added to Non-Opioid

Scores of 4–6 add codeine or tramadol to the base drug.

• 4–6 / 10: Pain band (moderate)
• 2: Core drugs (codeine, tramadol)
• Step 1: Combined with (non-opioid continues)
• Yes: Adjuvant option (as clinically indicated)

Step 2 drug class

Weak opioids layer onto the non-opioid, not replace it outright.

Escalation trigger

Persisting or rising pain moves treatment to Step 3.

Severe Pain — Strong Opioid ± Non-Opioid ± Adjuvant

Scores of 7–10 call for morphine, oxycodone, or fentanyl.

• 7–10 / 10: Pain band (severe)
• 3: Core drugs (morphine, oxycodone, fentanyl)
• Optional: Non-opioid base (may continue alongside)
• Yes: Adjuvant option (as clinically indicated)

Step 3 drug class

Strong opioids are selected once lower steps no longer suffice.

Not dose titration

This stage is about step choice, not individual dose adjustment.

The Ladder Is Not One-Directional

Pain is reassessed; the step moves up or down accordingly.

• Bidirectional: Direction (up or down as pain changes)
• Any step: Adjuvants (usable alongside any drug class)
• Ongoing: Reassessment (not a one-time decision)
• Match step: Goal (to current pain picture)

Stepping down

Improved pain control allows a lower step, not just escalation.

Adjuvants throughout

Neuropathic-pain adjuvants pair with any of the three steps.