MADISON, Wis--The World Health Organization (WHO), which first
published its analgesic ladder in the original 1986 version of
Cancer Pain Relief, has now issued an updated 2nd edition of the
book that includes additional alternative opioids such as hydromorphone,
oxycodone, and transdermal fentanyl, David E. Joranson, MSSW,
said at the WHO workshop on cancer pain at the 8th World Congress
The WHO approach to pain relief is to use simple technology and
a select group of drugs that should be available in all countries,
said Mr. Joranson, director of the Pain and Policy Studies Group
and WHO Collaborating Center for Policy and Communications in
Cancer Care, University of Wisconsin, Madison. He added that the
2nd edition addresses many of the advances in understanding and
practice that have arisen in the last 10 years.
The WHO analgesic ladder allows for the sequential use of progressively
stronger analgesic agents, in combination with adjuvant therapies
if indicated, such as antidepressants, anti-convulsants, corticosteroids,
and various nondrug therapies.
In step 1, a non-opioid is used. If this does not relieve the
pain, an opioid for mild to moderate pain should be added (step
2). If this combination strategy fails to relieve the pain, an
opioid for moderate to severe pain should be substituted, with
nonopioid and adjuvant therapies continued if appropriate (step
One Drug at a Time
Only one drug from each of the groups should be used at the same
time, the WHO guidelines recommend. If a step 2 opioid ceases
to be effective, the physician should prescribe a stronger agent
rather than switch to an alternative step 2 drug.
Morphine and some other opioids do not have a ceiling effect (when
increasing the dose above a certain level does not provide further
relief) and thus can be safely administered in increasing amounts
without risking an overdose, as long as side effects are tolerated.