Moreover, opioid rotation can beВ adopted to improve analgesia and reduce side effects. As many patients will receive opioids eventually, it is essential to balance the optimum dosage with the side effects of the drug. The key concept of the ladder is that it is essential to have adequate knowledge about pain, to assess its degree in a patient through proper evaluation, and to prescribe appropriate medications. For instance, the European Federation of Neurological Societies (ENS) recommended the use of duloxetine, or anticonvulsants, or a TCA for diabetic painful neuropathy treatment. Interestingly, although adjuvants are coadministered with analgesics, they are indicated as a first-line treatment option for the treatment of specific pain conditions. Adjuvants, also called co-analgesics, include antidepressants including tricyclic antidepressants (TCAs) such as amitriptyline and nortriptyline, serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine, anticonvulsants like gabapentin and pregabalin, topical anesthetics (e.g., lidocaine patch), topical therapies (e.g., capsaicin), corticosteroids, bisphosphonates, and cannabinoids. Although their administration isВ typically for indications other than pain treatment, these medications can be of particular help in various painful conditions.

The term adjuvantВ refers to a vast set of drugs belonging to different classes. Severe and persistent pain: potent opioids (morphine, methadone, fentanyl, oxycodone, buprenorphine, tapentadol, hydromorphone, oxymorphone) with or without non-opioid analgesics, and with or without adjuvants The original ladder mainly consisted of three steps : Nevertheless, it still provides a simple, palliative approach towards reducing morbidity due to pain in 70% to 80% of the patients. The efficiency of the strategy is debatable and yet to be proven through large-scale studies.

The analgesic ladder was part of a vast health program termed the WHO Cancer Pain and Palliative Care Program aimed at improving strategies for cancer pain management through educational campaigns, the creationВ of shared strategies, and the development of a global network of support.В This analgesic path, developed following the recommendations of an international group of experts, has undergone several modifications over the years and is currently applied for managing cancer pain but also acute and chronic non-cancer painful conditions due to a broader spectrum of diseases such as degenerative disorders, musculoskeletal diseases, neuropathic pain disorders, and other types of chronic pain. The WHO analgesic ladder was a strategy proposed by the World Health Organization (WHO), in 1986, to provide adequate pain relief for cancer patients.

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