Allan S. Brett, MD reviewing Bandieri E et al. J Clin Oncol 2016 Feb 10. Fallon M et al. J Clin Oncol 2016 Feb 20. Raman S et al. J Clin Oncol 2016 Feb 20.

One study challenges the WHO analgesic ladder, and another challenges the effectiveness of pregabalin for painful bone metastases.

Two recent studies in the Journal of Clinical Oncology add to our understanding of cancer pain treatments.

The World Health Organization's traditional three-step analgesic ladder consists of nonopioids, weak opioids, and strong opioids for treating patients with mild, mild-to-moderate, and moderate-to-severe cancer pain, respectively. But some experts argue that skipping weak opioids (step 2) and moving directly to low doses of so-called strong opioids (e.g., morphine) is reasonable when nonopioid analgesics are inadequate.

In an open-label randomized trial from Italy, researchers assigned 240 opioid-naive cancer patients with moderate pain to receive either step-2 analgesics (codeine or tramadol, usually combined with acetaminophen and titrated to maximal recommended doses) or oral immediate-release morphine (starting with 5 mg every 4 hours and transitioning eventually to slow-release equivalent dosage). During 4 weeks of follow-up, the morphine group achieved better pain control than did the weak-opioid group, with no higher incidence of side effects.

In a randomized double-blind trial from the U.K., researchers addressed the uncertain effectiveness of the anticonvulsant analgesic pregabalin for painful bone metastases in 233 patients, most of whom had breast, lung, or prostate cancer. Patients received radiotherapy plus 1 month of either pregabalin (titrated to a maximum dose of 300 mg twice daily) or placebo. At 1 month, the proportion of patients with adequate pain relief was virtually identical in both groups.

Citation(s):

Bandieri E et al. Randomized trial of low-dose morphine versus weak opioids in moderate cancer pain. J Clin Oncol 2016 Feb 10; 34:436.

Fallon M et al. Randomized double-blind trial of pregabalin versus placebo in conjunction with palliative radiotherapy for cancer-induced bone pain. J Clin Oncol 2016 Feb 20; 34:550. 

Raman S et al. Does pregabalin still have a role in treating cancer-induced bone pain? J Clin Oncol 2016 Feb 20; 34:524. 

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