WHO analgesic ladder and chronic pain: the need to search for treatable causesBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i597 (Published 04 February 2016) Cite this as: BMJ 2016;352:i597
All rapid responses
Many conditions can cause pain as a symptom. In these cases, pain is certainly a symptom and not a diagnosis. However, often persistent pain takes on clinical features not related to the underlying disease that caused it. Under these conditions the chronic pain becomes a real disease for suffering patients, even if sometimes the doctor is unable to diagnose a specific disease. With regard to treatment, the WHO ladder offers some advantages, but also some doubts of interpretation. In fact, it should be considered a hint and not a duty.
Recent studies indicate that drugs of the third step of WHO, administered at low doses, can induce greater benefits than the second step drugs (1). In addition, it should be emphasized that the WHO scale was drawn up many years ago when knowledge of opioids were less extensive than today. Currently chronic pain can be treated with multimodal therapy based on synergistic actions between drugs (2). In addition, many drugs of the first WHO step are not suitable for long-term treatment of elderly patients with high cardiovascular risk, therefore the use of opioids is necessary. I agree with the fact that these drugs should be prescribed with caution and monitored over time, in fact, the practitioner should handle opioids as manages antidepressants, antiepileptics, sleep inducers, etc. Many experts point out that the use of analgesic drugs must be based on experience and ability (3), and many strategies to monitor patients who require long treatment have been suggested (4).
I fully agree that before starting any therapy a diagnosis has to be established. However, when the unnecessary pain (mild, moderate or severe) is the predominant symptom, waiting for a clinical diagnosis, it is ethically correct to induce a relief of pain with the most appropriate medication. This approach should be applied in all settings, both in post surgical patients and in outpatients.
In conclusion, the three steps of WHO have an important role for clinicians, but it should be reviewed on the basis of new knowledge and available clinical trials. All analgesics have advantages and disadvantages: it is the task of the doctor to find the lowest effective dose or the best tolerated dose for an individual patient. Pharmacogenetic research will suggest how to implement personalized treatment strategies, as all hope, physicians and patients as well.
1. Bandieri E, Romero M, Ripamonti CI, et A. Randomized Trial of Low-Dose Morphine Versus Weak Opioids in Moderate Cancer Pain. J Clin Oncol. 2016 Feb 10;34(5):436-42
2. Gatti A, Sabato E., Di Paolo A.R, et Al. Oxycodone/paracetamol: a low-dose synergic combination useful in different types of pain. Clinical drug investigation 2010; 30(2): 3-14
3. Maremmmani I, Gerra G, Ripamonti IC et Al The prevention of analgesic opioids abuse: expert opinion. Eur Rev Med Pharmacol Sci. 2015 Nov;19(21):4203-6
4. Leonardi C, Vellucci R, Mammucari M et Al. Opioid risk addiction in the management of chronic pain in primary care: the addition risk questionnaire. Eur Rev Med Pharmacol Sci. 2015; 19(24):4898-905
Competing interests: No competing interests