Question 1

Should Step 2 be bypassed in severe cancer pain?

Accepted Answer

Yes — current evidence supports starting at Step 3 (low-dose strong opioid) for patients presenting with severe cancer pain, rather than requiring sequential step-up. This approach achieves faster pain control. The ladder should be used as a guide, not a rigid protocol. Low-dose morphine (5–10 mg oral) is appropriate first-line for severe pain.

Question 2

What adjuvants are recommended for neuropathic pain?

Accepted Answer

First-line adjuvants for neuropathic pain include gabapentinoids (gabapentin, pregabalin), tricyclic antidepressants (amitriptyline, nortriptyline), and serotonin-noradrenaline reuptake inhibitors (duloxetine, venlafaxine). These can be combined with opioids for synergistic effect.

Question 3

How should breakthrough pain be managed in a patient on regular opioids?

Accepted Answer

Breakthrough pain should be managed with a short-acting opioid at 10–20% of the total daily opioid dose, given as needed. For patients on stable long-acting opioids, consider rapid-onset formulations (oral transmucosal fentanyl) for predictable incident pain. Persistent breakthrough pain (>4 episodes/day) signals the need to increase the regular dose.

Question 4

Can the WHO ladder be applied to chronic non-cancer pain?

Accepted Answer

With caution — the evidence for opioid efficacy in chronic non-cancer pain is limited, and risks of tolerance, opioid-induced hyperalgesia, and dependence are significant. Multimodal analgesia, non-pharmacological therapies, and judicious opioid use with strict monitoring are recommended. The ladder was designed primarily for cancer pain.