Adjuvant analgesic ladder

APPRAISING THE WHO ANALGESIC LADDER ON ITS 20TH ANNIVERSARY

September 6, 2013 – 11:05

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THE FACTS1986: WHO publishes "Cancer Pain Relief", the first edition of the WHO method for the relief of cancer pain.

2006: 20th anniversary of the WHO method for the relief of cancer pain.

Over the course of the last 20 years, the WHO method for the relief of cancer pain, also known as the three-step analgesic ladder has been debated, praised for its simplicity and clarity, criticized for its omissions.

In this issue, we ask Dr. Kathleen Foley, former chair of the WHO Expert Committee on Cancer Pain Relief and Active Supportive Care--the group that drafted the WHO guidelines, to reflect on the last 20 years, address the main points of the ongoing debate, specify where new evidence suggests areas for refinements and place the WHO ladder in perspective.

--Sophie M. Colleau, PhD

An interview with Kathleen M. Foley, MD*

* Dr. Kathleen M. Foley is an Attending Neurologist in the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center in New York City. She is Professor of Neurology, Neuroscience and Clinical Pharmacology at Weill Medical College of Cornell University, and holds the Chair of the Society of Memorial Sloan-Kettering Cancer Center in Pain Research. She is the former Chair of the WHO Expert Committee on Cancer Pain Relief and Active Supportive Care (1982-1998).

Q: Twenty years ago, the World Health Organization (WHO) published Cancer Pain Relief, the small book that set out the principles of cancer pain management including the use of the three-step analgesic ladder. In what context was the WHO ladder developed?
A: The WHO ladder came about as the result of the efforts of the Cancer Unit of the World Health Organization to develop national cancer control programs globally. The majority of patients in resource poor settings typically present with advanced cancer and are not candidates for prevention or for curative therapies. Such patients with advanced illness have numerous symptoms, most commonly severe pain and are appropriate candidates for palliative and hospice care services. The WHO argued that every national cancer control program should include palliative care services and make pain relief available to all patients with advanced illness.

Q: What are the key principles of the WHO method to relieve cancer pain?
A: The WHO method can be summarized in five phrases: "by mouth", "by the clock", "by the ladder", "for the individual" and "attention to detail." These five phrases embody the concept that analgesic drug therapy is key to managing pain in the majority of patients with cancer and that a strong opioid is an absolute necessity to control severe pain for the majority of people.

Q: What do the steps of the ladder represent?
A: The steps illustrate the process of selecting a specific drug for a specific type of pain based on the intensity of the pain. Each step represents the drugs that are effective for mild pain, moderate pain and severe pain. For example, a patient with mild pain should be started on paracetamol or aspirin or one of the nonsteroidal anti-inflammatory drugs (NSAIDs). At each step of the ladder the specific analgesic drug can be combined with an adjuvant drug. Adjuvant drugs may not be primarily analgesic in their mechanism of action, but have analgesic effects in certain pain conditions. Adjuvant is also the term used to describe drugs that may be useful in controlling side effects of opioids.

Source: www.whocancerpain.wisc.edu

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