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.