Effectiveness of the WHO analgesic ladder for malignancy pain: Systematic literature review

Abstrak

Background: Inadequately managed malignancy pain severely compromises patients' quality of life. This study synthesizes scientific evidence regarding the effectiveness of standard and modified WHO Analgesic Ladders in reducing pain intensity.

Method: Following PRISMA guidelines, 15 quantitative studies (RCTs and cohorts) published between 2010–2025 were identified via PubMed, ScienceDirect, and Cochrane Library, and manual searches via Google.

Results: Methodological quality was assessed using JBI Critical Appraisal Tools, revealing 4 studies with a low risk of bias (score ≥75%) and 11 with a moderate risk (50–75%). The standard WHO ladder remains highly effective in pediatric populations, achieving 85%–100% pain control. In adults, a modified two-step approach (bypassing weak opioids) demonstrated significant superiority, with pain reduction response rates of 76.5%–88.2%, compared to only 32.35%–54.7% for weak opioids. Standard adult application yielded 64.5%–73.8% effectiveness, which rose to 91.25% when supported by strict management cycles. Integrating multimodal therapies further reduced daily opioid requirements while significantly improving Quality of Life (QOL). Precise assessment using Wong-Baker (children) or NRS/VAS (adults) remains essential.

Conclusion: Transitioning to a two-step approach and integrating multimodal therapies offers a more optimal, faster, and statistically superior strategy for modern malignancy pain management.