In a 28-day multicentre Randomized Control Trial, adults with moderate cancer pain were assigned to receive either a low dose of oral morphine, or a weak opioid.
The primary outcome was: “the number of responder patients, defined as patients with a 20% reduction in pain intensity on the numerical rating scale.”
This occurred in 88.2% of the low-dose morphine and in 57.7% of the weak-opioid group.
The authors concluded that: “In patients with cancer and moderate pain, low-dose morphine reduced pain intensity significantly compared with weak opioids, with a similarly good tolerability and an earlier effect.”
This calls into question the WHO three-step ladder, adding evidence instead for a two-step ladder. This issue is in accordance with the latest European Association for Palliative Care recommendations, and will be addressed in the upcoming development of new WHO guidelines for persisting pain in adults.
Professor Stein Kaasa, Professor of Palliative Medicine at the Institute of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, in an editorial for the Journal of Clinical Oncology, congratulated the researchers on their “major contribution” to the field of cancer care.
However, he cautioned that the design of the study made it difficult to tell whether the outcomes were the result of the different medications themselves, or a difference in titration, with the intervention group having their medication titrated according to international guidelines, whereas it is unclear whether this took place in the control group.
Prof Kaasa noted that the study: “may nonetheless contribute to improved patient care by providing evidence to support simplifying the WHO pain ladder by skipping the second step.”
He concluded: “Pain control must be part of a strategy that includes control of other symptoms, psychosocial support, and integration between oncology and palliative care services to meet the complex needs of patients and their families.”
Prof Kaasa suggested that from a global perspective, a simple policy to work towards would be: Global availability of one opioid, that is morphine. He said: “There is no reason to believe from a basic pain treatment perspective that any other (more expensive) opioid is needed.”
You can access the original article, as well as Prof Kaasa’s editorial on the Journal of Clinical Oncology website.
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