Synopsis
Use the WHO cancer-pain framework as a flexible guide, combine mechanism-specific medicines with disease treatment, rehabilitation and psychosocial care, and avoid reflex opioid escalation when a different modality offers greater benefit.
- The WHO ladder was developed for cancer pain: non-opioid at step one, opioid for mild-to-moderate pain at step two and strong opioid at step three, with adjuvants throughout.
- Use the ladder flexibly rather than forcing slow progression; severe cancer pain may require a carefully started strong opioid without a prolonged weak-opioid trial.
- Core principles are an appropriate route, regular treatment for continuous pain, rescue for breakthrough pain, individual titration and attention to detail.
Key red flags
New neurological deficit, pathological fracture features or visceral obstruction requires urgent cause-directed treatment rather than analgesic escalation alone.
Escalating toxicity without functional gain suggests the formulation or target is wrong and warrants specialist reassessment.
Investigation priorities
Identify nociceptive, neuropathic, inflammatory, mechanical and psychosocial contributors and the need for urgent disease treatment.
Management branches
Pain requires a new or revised treatment plan after emergency causes have been addressed.
- Formulate pain mechanisms and severity, define a functional goal and identify disease-directed, physical and psychosocial treatments that can alter the cause.
- Select non-opioid, opioid and adjuvant components with organ function and interactions considered, moving directly to carefully titrated strong opioid when severe cancer pain warrants it.
Key medicines
Paracetamol for selected nociceptive painFor an adult at least 50 kg without relevant risk, 500 mg to 1 g orally every 4 to 6 hours when required, maximum 4 g in 24 hours; use a lower maximum when low weight, frailty, malnutrition, alcohol excess or liver disease requires it.
Ibuprofen as a short anti-inflammatory trialWhen appropriate, use 200 to 400 mg orally up to three times daily with or after food for the shortest necessary course, following the BNF and local gastroprotection policy.