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A modern analgesics pain ‘pyramid’

In an effort to provide guidance for the use of analgesics for pain management – while at the same time acknowledging the professional, patient and regulatory–legal concerns about the use of strong opioids – the World Health Organization (WHO) in 1986 suggested a conservative stepwise approach. In addition to the use of non‐pharmacologic measures, the WHO recommended that pharmacotherapy be initiated using a non‐opioid analgesic first and then progress through ‘weak’ opioids or analgesic combinations to ‘strong’ opioids if, and only if, needed. This approach gave a rationale, and a justification if necessary, for the use of opioids. This stepwise approach became widely known as the WHO analgesic ‘ladder’.