A validation study of the WHO analgesic ladder: a two-step vs three-step strategy

Support Care Cancer. 2005 Nov;13(11):888-94. doi: 10.1007/s00520-005-0807-6. Epub 2005 Apr 8.


Goals of work: The aims of the present study were to verify whether an innovative therapeutic strategy for the treatment of mild-moderate chronic cancer pain, passing directly from step I to step III of the WHO analgesic ladder, is more effective than the traditional three-step strategy and to evaluate the tolerability and therapeutic index in both strategies.

Methods: Patients aged 18 years or older with multiple viscera or bone metastases or with locally advanced disease were randomized. Pain intensity was assessed using a 0-10 numerical rating scale based on four questions selected from the validated Italian version of the Brief Pain Inventory. Treatment-specific variables and other symptoms were recorded at baseline up to a maximum follow-up of 90 days per patient.

Results: Fifty-four patients were randomized onto the study, and pain intensity was assessed over a period of 2,649 days. The innovative treatment presented a statistically significant advantage over the traditional strategy in terms of the percentage of days with worst pain > or =5 (22.8 vs 28.6%, p < 0.001) and > or =7 (8.6 vs 11.2%, p = 0.023). Grades 3 and 4 anorexia and constipation were more frequently reported in the innovative strategy arm, although prophylactic laxative therapy was used less in this setting.

Conclusions: Our preliminary data would seem to suggest that a direct move to the third step of the WHO analgesic ladder is feasible and could reduce some pain scores but also requires careful management of side effects.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Algorithms
  • Analgesics, Opioid / adverse effects
  • Analgesics, Opioid / classification
  • Analgesics, Opioid / therapeutic use*
  • Anti-Inflammatory Agents, Non-Steroidal / adverse effects
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use*
  • Clinical Protocols*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Neoplasms / complications*
  • Pain / drug therapy*
  • Pain / etiology
  • Palliative Care / standards*
  • Patient Satisfaction
  • Reproducibility of Results
  • World Health Organization


  • Analgesics, Opioid
  • Anti-Inflammatory Agents, Non-Steroidal