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In 1986, the World Health Organization (WHO) developed a simple model for the slow introduction and upward titration of analgesics, which became known as the WHO analgesic stepladder. 1 Before this, people were dying in unnecessary pain because drug regulations introduced earlier in the century had increased the stigma and fear associated with both prescribing and taking opioids.
The underlying principle was that analgesics should be used incrementally, starting with non-opioids, progressing through mild and finally strong opioids, dosed in accordance with the patient's reported pain intensity. It was expected that opioids would be needed in increasing doses to overcome pain as cancer progressed. The goal was to allow patients to be as comfortable and interactive as possible during the short march towards death. Risks of addiction and hastened death were accepted in the principle of double effect: comfort is paramount. 2
The stepladder approach had tremendous value when it was introduced because it legitimised the use of opioids, overcoming prejudicial and regulatory stigmas that had hampered compassionate pain care, especially for patients dying from cancer. The success of opioid treatment in terminally ill cancer patients set the stage for extending the same moral imperative and treatment principles to the treatment of chronic pain, where previously opioids were considered too risky or not effective. 3 4 Suddenly, because chronic pain is ubiquitous and open ended, the floodgates opened. Over the past 30 years, in much of the developed world, we have seen more patients treated with opioids at higher doses than ever before. The extent to which the more liberal use of opioids would cause harm was not predicted.
The increase in opioid prescribing and its adverse consequences are nowhere more obvious than in the United States, where...