Multinational randomized trial of comparing two-step versus standard three-step approach of the WHO analgesic ladder in cancer patients

Cancer pain management usually follows the WHO three step analgesic ladder. Using weak opioids (e.g. codeine) at step two is debatable with low dose strong opioids potentially better. A multinational randomized trial evaluated omitting step two of the ladder. The trial found no statistically significant difference in time to stable pain control between patients randomized to step two (control arm) or to step three (intervention arm), with 53% of patients in the control arm needing to change to a strong opioid due to ineffective analgesia. The median time to change was 6 days (IQR 4-11). Compared to the control arm, patients in the experimental arm had less nausea (p=0.009) and costs were less. The authors conclude that the trial provides some evidence that a two-step approach is an alternative option for cancer pain management.