6533b7d4fe1ef96bd12628b6

RESEARCH PRODUCT

World Health Organization guidelines for cancer pain: a reappraisal

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Pain is a prevalent symptom experienced by at least 30% ofpatients undergoing an oncological treatment for metastaticdisease and by more than 70% of advanced cancer patients[1]. In 1986 the World Health Organization [2] published a setof guidelines for cancer pain management based on the three-step analgesic ladder [2]. The main aim of WHO guidelienswas to legitimize the prescribing of strong opioids, arisingfrom evidence of poor management of cancer pain, due toreluctance of health care professionals, institutions, and gov-ernment to use opioids because of fears of addition, toleranceand illegal abuse.Its application is reported to achieve satisfactory pain reliefin up to 90% of patients with cancer pain. Despite the largeexperience proving the feasibility and efficacy [3–5], in theyears of evidence-based medicine, the three-step ladder hasbeen criticized for the lack of robust data supporting thisapproach. Studies validating the WHO analgesic ladder hadmethodologic limitations including the circumstances duringwhich assessment were made, small sample size, retrospectiveanalyses, high rate of exclusions and dropout, inadequatefollow-up, and a lack comparison with levels of analgesiabefore the introduction of the analgesic ladder [6].Thus, different problems are unresolved due a lack of con-trolled studies on this subject. These problems include, forexample, a better definition of the role of NSAIDs, the pro-longed use of NSAIDs in cancer pain, and the utility of step 2.Moreover, the indications for using different strong opioidsand alternate routes of administration to improve pain relief indifficult pain situations are not well established. The pro-portion of patients who do not benefit from these treatmentsremain unclear, and how the opioid response may be improvedwith the use of adjuvants is also uncertain. Finally, differentcountries apply the WHO ladder approach differently depend-ing on the availability of drugs.