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Pain is one of the most common symptoms in cancer patients and often has a negative impact on patients’ functional status and quality of life.

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A commonly used approach to pain management employs the World Health Organization (WHO) pain relief ladder, which categorizes pain intensity according to severity and recommends analgesic agents based on their strength.[4] Pain intensity is often assessed using a numeric rating scale (NRS) of 0 to 10.

On this scale, 0 indicates no pain, 1 to 3 indicates mild pain, 4 to 6 indicates moderate pain, and 7 to 10 indicates severe pain.[5] Step 1 on the WHO pain relief ladder treats mild pain.

Patients in this category receive nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, or an adjuvant analgesic, if necessary.

Step 2 treats patients experiencing mild to moderate pain who are already taking a nonopioid analgesic, with or without an adjuvant analgesic, but who are still experiencing poor analgesia.

Step 2 agents include tramadol and acetaminophen products containing hydrocodone, oxycodone, and codeine.

Step 3 treats moderate to severe pain with strong analgesics.

Step 3 opioids include morphine, hydromorphone, fentanyl, levorphanol, methadone, oxymorphone, and oxycodone.

An open-label randomized trial of low-dose morphine versus weak opioids to treat moderate cancer pain suggests that it is acceptable to bypass weak opioids and go directly to strong opioids (step 3 agents) for patients with moderate cancer pain, as patients randomly assigned to the low-dose morphine arm had more frequent and greater reduction in pain intensity with similarly good tolerability and earlier effect.[6] Familiarity with opioid pharmacokinetics, equianalgesic dosing, and adverse effects is necessary for their safe and effective use.

The appropriate use of adjuvant pharmacological and nonpharmacological interventions is needed to optimize pain management.

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