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(Drug information on hydromorphone), oxycodone(Drug information on oxycodone), and transdermal fentanyl(Drug information on fentanyl), David E. Joranson, MSSW, said at the WHO workshop on cancer pain at the 8th World Congress on Pain.
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 3).
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(Drug information on 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.