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Am Fam Physician. 1999;60(2):608-610

Managing cancer pain at the end of life is possible using a relatively simple approach developed by the World Health Organization (WHO). These guidelines consist of a three-step analgesic ladder that advocates the use of gradually more potent medications as the intensity of a patient's pain increases. The sequence begins with nonopioid analgesics for mild pain, followed by moderately strong opioids for moderate pain and strong opioids for severe pain. Mercadante conducted a long-term prospective study to evaluate the effectiveness, safety and feasibility of using the WHO approach for pain management in patients with advanced cancer.

Patients with advanced cancer who were unresponsive to conventional cancer treatment and thus referred to a home palliative care program were eligible for the study. All received pain medications based on the WHO guidelines. Dosages were kept as low as possible initially but were increased when patients reported that the intensity of pain was unacceptable. Use of adjuvant therapy was also allowed in these patients. Data on the type of pain syndrome, performance status, pain intensity, symptoms associated with opioid use or advanced cancer, and dosages plus days of medications were obtained at baseline, after one week of treatment and in the last week of life.

Of the 3,557 patients eligible for the study, 2,500 patients with cancer pain requiring analgesic therapy were admitted to a home palliative care program. The mean duration of home assistance until death was 64 days. The mean duration periods for each of the steps were 18, 27 and 19 days, respectively. For more information, see the accompanying table on movement through the different steps of pain management. Pain intensity decreased significantly within three days from the time of admission, and this decrease was maintained until death. Only 20 percent of patients were taking step 1 drugs in the last week of life, while step 2 drugs were used more frequently throughout the treatment and in the last week of life. Step 3 drugs were used in 25 percent of patients, as only 263 patients rated their pain intensity around the time of death as higher than 4 on a scale of 10. Adjuvant drugs were used on 79 percent of all treatment days, most commonly coanalgesics, laxatives, antiemetics and, in some instances, steroids. Most opioid-related adverse effects, including constipation, dry mouth and vomiting, were rated as acceptable by patients.

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The author concludes that the WHO guidelines for pain management should be strongly recommended for use in patients with advanced cancer. In this study, pain intensity was reduced to tolerable levels with minimal side effects in almost all patients. Pain control was achieved within a short period of time and was maintained for most of the patient's time in the program. Use of the WHO guidelines enables the patient to manage pain using a variety of drugs while remaining in a home setting. Providing care in the home can reduce the patient's anxiety and feelings of powerlessness at the end of life. By using these guidelines, effective quality care can be provided in the home with minimal adverse effects.

editor's note: Pain is the aspect associated with a life-limiting disease that is most commonly feared. Despite the wide variety of pain medications, studies show that physicians still under-treat pain in patients with terminal illnesses. The WHO step-ladder approach presented in this study significantly reduced pain in most patients with virtually no significant adverse events. Physicians must understand how to treat pain aggressively in patients with terminal illnesses to improve their quality of life.—k.m.

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