Module 4: Therapeutics

Lesson 2

Prescribing opioids

The World Health Organization’s (WHO) Pain Ladder was originally created in 1986 to address the potential for under treatment of excruciating and short-term pain by providing a simple tool for clinicians to use to initiate and titrate opioids. The introduction of this approach legitimized opioids for the treatment of pain and contributed to the health care community’s transition away from the fear of prescribing these agents for those who required compassionate pain care.

While this approach may be appropriate for acute pain and cancer pain, its applicability to chronic non-malignant pain is problematic. Ballantyne, Kalso, and Stannard (2016) succinctly point out that the notion that opioids can be titrated to reliably improve quality of life and overall pain intensity in chronic non-malignant pain may expose patients to harm and create unrealistic expectations.

In addition to the Pain Ladder, WHO principles are important to consider for acute and cancer pain and also contain some information that is appropriate for chronic non-cancer pain.


  • Ballantyne, J. C., Kalso, E., & Stannard, C. (2016). WHO analgesic ladder: a good concept gone astray. BMJ, 352, i20. doi: