WHO Analgesic Ladder Research Articles

P226 Prevalence and treatment of pain in hospital in-patients with respiratory disease

Introduction and objectivesPain is common, with 43% of medical inpatients experiencing moderate to severe pain [Dix et al BJA 2004;92(2):235–237]. Factors contributing to inadequate pain relief include concerns about analgesic...

The impact of tramadol and dihydrocodeine treatment on quality of life of patients with cancer pain

Tramadol and dihydrocodeine (DHC) are analgesics of step 2 WHO analgesic ladder (opioids for mild to moderate pain, weak opioids) frequently used in the treatment of cancer pain of moderate intensity. The aim of the study was to assess the impact of tramadol and DHC treatment on quality of life (QL) and performance status (PS) of patients with cancer pain. Randomised, cross-over, clinical study of 40 opioid-naive patients with nociceptive cancer pain who received tramadol or DHC controlled release tablets for 7 days, and then drugs were switched and administered for another 7 days. Pain was assessed by visual analogue scale (VAS), QL by EORTC QLQ C 30, and PS by Eastern Cooperative Oncology Group (ECOG) and Karnofsky. From 40 patients recruited, 30 completed the study. DHC treatment provided better analgesia (VAS). In QL functional scales, better emotional functioning in tramadol group and better global QL and cognitive functioning in DHC group were observed. In symptom scales, less fatigue, pain and sleep disturbances, less nausea and vomiting and better appetite in DHC group were noted. In tramadol group, less constipation and less financial problems were observed. No differences in dyspnoea and diarrhoea were noted. ECOG and Karnofsky PS were low and did not differ between tramadol and DHC groups. Dihydrocodeine treatment was associated with better global QL, cognitive functioning, analgesia and appetite, less fatigue, sleep disturbances, nausea and vomiting. Tramadol therapy was connected with better emotional functioning, less constipation and financial problems. PS deteriorated in both tramadol and DHC groups.

Management of cancer pain

In the last decades, studies validating the WHO analgesic ladder have been shown to have methodological limitations and different problems are unresolved due to a lack of controlled studies on this subject. These problems include a better definition of the role of NSAIDs, the prolonged use of NSAIDs in cancer pain, and the utility of step 2. Moreover, the indications for using different strong opioids and alternate routes of administration to improve pain relief in difficult pain situations are not well established. The proportion of patients who do not benefit from these treatments remain unclear, and how the opioid response may be improved with the use of adjuvants is also uncertain. This review will offer an update on these problems and the existing therapeutic opportunities.

Befragung schmerztherapeutisch interessierter Ärzte zum Umgang mit Opioiden

The efficacy of opioids has been proved and several guidelines and expert panel-based recommendations regarding the use of opioids in different pain syndromes are available. Nevertheless, undertreatment of pain with strong opioids was reported in previous studies. It was shown that physicians' lack of knowledge, their concerns and misconceptions about the opioid use and the controlled substances regulations that govern the prescriptions of opioids occasionally contribute to insufficient pain treatment. This study was designed to evaluate German physicians' knowledge and their concerns about the use of opioids. During a postgraduate course a questionnaire was completed by German physicians specializing in pain therapy. A total of 226 physicians completed the questionnaire (response rate 57%). Many of them had poor knowledge of the WHO recommendations for the treatment of cancer pain including the WHO analgesic ladder. Deficiencies in the knowledge of pharmacological aspects and controlled substances regulations were revealed. Many physicians would prescribe strong opioids for non-opioid-sensitive types of pain. The concerns regarding opioid therapy included adverse effects and addiction. In contrast to earlier findings the German controlled substances regulations no longer seem to be a barrier to the prescription of opioids in the treatment of chronic severe pain since they were changed in 1998. As a result, the lack of knowledge and the physicians' concerns about the use of opioids as shown in this survey may likely lead to an insufficient treatment of patients suffering from severe chronic pain. It is necessary to improve the medical students' education and the physicians' postgraduate training regarding principles of pain management such as the WHO guidelines for the treatment of cancer pain. A better knowledge of important pharmacological aspects of opioids should help to reduce physicians' concerns about the use of strong opioids. Nevertheless, improvement of physicians' skills in pain therapy is only one aim in a multidisciplinary concept in order to improve patients' pain therapy.

Management of pain in leukemic children using the WHO analgesic ladder

To ascertain the effectiveness of WHO analgesic ladder in pain management in children with leukemia. Children with leukemia who were referred to a pain and palliative care clinic attached to the Department of Pediatrics of a medical teaching hospital during a period of 6 months were included in the study. Thirty nine (39) children, who constituted 64% of children on treatment for leukemia, required referral to pain and palliative care services during the study period. Of these 92% had Acute Lymphocytic Leukemia (ALL) and 8% had Acute Non Lymphocytic Leukemia (ANLL). 95% of children had nociceptive pain and 5% had neuropathic pain. Step - 1 analgesia was effective in 12 (31%) children and 21 (54%) could be managed with Step - 2 analgesia. Step - 3 analgesia was required in only 6 (15%) children. Step 3 analgesia was required in children with neuropathic pain and bone pain. WHO analgesic ladder is effective in managing pain in children with leukemia. Majority of cases of cancer pain in children could be managed by the treating physician using non-opioids, weak opioids and adjuvants as per the WHO guidelines. Children with bone pain and neuropathic pain may require referral to specialist services and use of strong opioids like morphine. The study emphasizes the need for establishing specialist pain management services in all centres where children with cancer are treated.

Evidence based guidelines for complex regional pain syndrome type 1

BackgroundTreatment of complex regional pain syndrome type I (CRPS-I) is subject to discussion. The purpose of this study was to develop multidisciplinary guidelines for treatment of CRPS-I.MethodA multidisciplinary task force graded literature evaluating treatment effects for CRPS-I according to their strength of evidence, published between 1980 to June 2005. Treatment recommendations based on the literature findings were formulated and formally approved by all Dutch professional associations involved in CRPS-I treatment.ResultsFor pain treatment, the WHO analgesic ladder is advised with the exception of strong opioids. For neuropathic pain, anticonvulsants and tricyclic antidepressants may be considered. For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. To promote peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used to increase blood flow in case vasodilatory medication has insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, vitamin C is recommended. Adequate perioperative analgesia, limitation of operating time, limited use of tourniquet, and use of regional anaesthetic techniques are recommended for secondary prevention of CRPS-I.ConclusionsBased on the literature identified and the extent of evidence found for therapeutic interventions for CRPS-I, we conclude that further research is needed into each of the therapeutic modalities discussed in the guidelines.

Ibandronate Shows Marked Pain Relief and a Favorable Renal Safety Profile – Updated Results of a Non Interventional Study in Breast Cancer Patients with Metastatic Bone Disease.

Abstract Background: Bisphosphonates (BP), the current standard of care for patients with metastatic bone disease (MBD) due to breast cancer (BC), effectively reduce the incidence of skeletal related events (SRE) and the severity of bone pain. However, BP treatment may adversely affect kidney function and thus renal safety is a key determinant of BP risk/benefit assessment. In randomized clinical trials (RCT), Ibandronate (IBA), a third generation amino-BP available in IV and oral formulations, has demonstrated sustained effects on SRE and bone pain with a low incidence of renal adverse events. To verify those results under real life conditions, a large-scale non interventional study (NIS) is currently being conducted in Germany.Patients and methods: In accordance with the terms of the marketing authorization, BC patients with MBD receive 6 mg IBA IV every 3–4 weeks or 50 mg of oral IBA once daily (at the physician's discretion) for up to 24 weeks. Pain severity (VAS), analgesic use (WHO analgesic ladder), SRE, and renal function (serum creatinine levels and estimated creatinine clearance, eCrCl; Cockcroft-Gault formula) are recorded in 4-week-intervals.Results: For this interim analysis, data for 2676 patients, mean age 63.6 ±11.8 years, were evaluated. 1735 (65%) were BP-naïve; 317 (12%) had received prior treatment with IBA, 614 (23%) with other BPs, including zoledronic acid (ZOL) (393; 15%) and pamidronate (PAM) (210; 8%). At baseline, mean pain severity (VAS) was lower for patients pretreated with IBA (2.7 ± 2.2) compared to BP-naïve patients (3.3 ± 2.4; p < 0.0001) or patients pretreated with other BPs (3.2 ± 2.4; p= 0.0041) and analgesic use was less frequent (38% vs 49% and 47%, respectively).In patients reporting pain at baseline, mean pain severity decreased on IBA treatment throughout the observation period (VAS: 3.2 ± 2.4 to 2.4 ± 2; p < 0.0001). In parallel, there was an overall reduction of analgesic use with 57% of patients not requiring analgesics at the end of the observation period. SRE were rare (7%), irrespective of prior treatment. For patients evaluable for renal function throughout the observation period, mean eCrCl at baseline was significantly lower in patients pretreated with ZOL (70.7 ml/min) than in BP-naïve (78.9 ± 30.9 ml/min; p < 0.0001) or IBA-pretreated patients (78 ± 29.1 ml/min; p=0.00386). Changes in renal function during IBA treatment were small and balanced across all subgroups. Overall tolerability of IBA treatment was rated as very good or good by 96% of physicians and patients alike.Conclusion: In this interim analysis of a large scale NIS in BC patients with MBD, IV and oral IBA showed marked and sustained pain relief with an overall reduction of analgesic use and a renal safety profile comparable to results of RCTs. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1108.

The Role of Interventional Therapies in Cancer Pain Management

Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. These cancer patients can also suffer from intolerable adverse effects of drug therapy or intractable cancer pain in advance disease. Though the prognosis of these cancer patients is often very limited, the pain relief, reduced medical costs and improvement in function and quality of life from a wide variety of available interventional procedures is extremely invaluable. These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed.

The Early Detection and Management of Neuropathic Pain Following Combat Injury

The mechanism of injury on the modern battlefield results in a pattern of wounding which is associated with both nociceptive and neuropathic pain. Nociceptive pain is managed using the WHO...

Co-morbidity and utilization of medical services by pain patients receiving opioid medications: Data from an insurance claims database

We used a large medical insurance claims database to identify three groups: chronic opioid use (>180 therapeutic days, N=3726); acute opioid use (<10 therapeutic days, N=37,108); and a non-opioid group (N=337,366) who filed at least one insurance claim but none for opioids. Our results showed that although chronic opioid users represented only 0.65% of the total population, they filed 4.56% of all insurance claims, used 45% of all opioid analgesics and had much more physical and psychiatric co-morbidity than the acute opioid or non-opioid samples. Women were substantially over-represented (>63%) in the chronic pain group and used a much greater share of all medical services than males, especially as they grew older. Although our data suggest that chronic pain is optimally managed in a multidisciplinary patient- and gender-specific treatment plan, this was rarely the case with internists being the primary, and often only, physician seen. Moreover, our data suggest that opioids were often used for conditions in which they are generally not indicated (e.g. arthritis and headaches) or contraindicated by co-existing physical ailments (COPD). Finally, we conclude that adherence to the WHO analgesic ladder and other pain treatment guidelines was relatively infrequent: first, opioid extended release preparations which are ideally suited for chronic pain were used only in one in four patients; and, second, the selection of a weak (propoxyphene, codeine, and tramadol) or strong opioid (e.g. morphine and oxycodone) seemed to be driven by numerous factors not necessarily related to the intensity or duration of pain.

Evolución del consumo de opiáceos en dos áreas sanitarias de Atención Primaria de la Comunidad de Madrid (España) y sus hospitales de referencia entre los años 2002 y 2006

Describe the evolution of prescription opioids from 2002 to 2006 in Primary Health Care Area 2 and 5 in the Madrid Community and its referral hospitals (University Hospitals of la Princesa and La Paz). A retrospective observational study of prescriptions made by calculating defined daily doses per million inhabitants. In Primary Care, transdermal fentanyl (78.39% of the total in 2006 in area 2 and 76.69% in the area 5) is the opioid prescribed most on the third step on the WHO analgesic ladder. This is followed by buprenofin (12.30% and 13.23%) and morphine (6.94% and 8.45%). As for the second step, tramadol is the most prescribed opioid with 85.12% and 83.56% of total consumption. We see a growth in consumption in the third step that goes from a defined daily doses per one million inhabitants of 897.67 in 2003 in area 5 and 1056.42 in area 2 to 1490.15 and 1601.48, respectively in 2006 and the second step goes from 1545.25 and 1629.94 in 2003 to 1904.70 and 1730.66 in both areas in 2006. In the hospitals analyzed, there is a similar progression, with a gradual increase in the use of fentanyl and a trend towards reduction in the consumption of morphine. Our data reflect the increase in consumption of opioids, despite declining morphine. It is noteworthy that transdermal fentanyl is the opioid prescribed most.

Prostate cancer with bone metastasis: an overview of pain assessment and management

AbstractThe challenges of assessing and assisting men with chronic progressive metastatic bone pain secondary to prostate cancer can be immense. All patients have a right to have their pain assessed and relieved by knowledgeable health professionals, yet many urology outpatient clinic nurses come from a surgical background and have limited skills and knowledge in this area. This article aims to enhance the knowledge of urology nurses, by critically analysing and discussing components of current pain management practice, for men with painful bone metastasis. To this end, the pathophysiology of metastatic bone pain is briefly outlined followed by pain definitions from literature and information pertaining to assessment of bone pain. Barriers to effective pain assessment are identified, along with a brief discussion on the impact of factors like fatigue, anxiety and depression on pain. A review is undertaken of selected pharmacological and non‐pharmacological strategies for the management of bone pain, as reported in published literature. Knowledge of the WHO analgesic ladder for cancer pain and the actions of pain‐relieving medications and their adjuncts will better equip nurses to educate patients regarding their effective use. Insights gained into potentially effective non‐pharmacological strategies for the reduction of the experience of pain should prompt nurses to investigate what modalities are on offer at their place of work and within their local community. Written resources can then be created to share this information with patients if they are not already in existence.

Interventional Pain Treatments for Cancer Pain

Cancer pain is prevalent and often multifactorial. For a segment of the cancer pain population, pain control remains inadequate despite full compliance with the WHO analgesic guidelines including use of co-analgesics. The failure to obtain acceptable pain or symptom relief prompted the inclusion of a fourth step to the WHO analgesic ladder, which includes advanced interventional approaches. Interventional pain-relieving therapies can be indispensable allies in the quest for pain reduction among cancer patients suffering from refractory pain. There are a variety of techniques used by interventional pain physicians, which may be grossly divided into modalities affecting the spinal canal (e.g., intrathecal or epidural space), called neuraxial techniques and those that target individual nerves or nerve bundles, termed neurolytic techniques. An array of intrathecal medications are infused into the cerebrospinal fluid in an attempt to relieve refractory cancer pain, reduce disabling adverse effects of systemic analgesics, and promote a higher quality of life. These intrathecal medications include opioids, local anesthetics, clonidine, and ziconotide. Intrathecal and epidural infusions can serve as useful methods of delivering analgesics quickly and safely. Spinal delivery of drugs for the treatment of chronic pain by means of an implantable drug delivery system (IDDS) began in the 1980s. Both intrathecal and epidural neurolysis can be effective in managing intractable cancer-related pain. There are several sites for neurolytic blockade of the sympathetic nervous system for the treatment of cancer pain. The more common sites include the celiac plexus, superior hypogastric plexus, and ganglion impar. Today, interventional pain-relieving approaches should be considered a critical component of a multifaceted therapeutic program of cancer pain relief.

Cancer Pain and Analgesia

Pain ranges in prevalence from 14-100% among cancer patients and occurs in 50-70% of those in active treatment. Cancer pain may result from direct invasion of tumor into nerves, bones, soft tissue, ligaments, and fascia, and may induce visceral pain through distension and obstruction. Cancer pain is multifaceted. Clinicians may describe cancer pain as acute, chronic, nociceptive (somatic), visceral, or neuropathic. Despite implementation of the WHO guidelines, reports of undertreatment of cancer pain persist in various clinical settings and in spite of decades of work to reduce unnecessary discomfort. Substantial obstacles to adequate pain relief with opioids include specific concerns of patients themselves, their family members, physicians, nurses, and the healthcare system. The WHO analgesic ladder serves as the mainstay of treatment for the relief of cancer pain in concert with tumoricidal, surgical, interventional, radiotherapeutic, psychological, and rehabilitative modalities. This multidimensional approach offers the greatest potential for maximizing analgesia and minimizing adverse effects. Primary therapies are directed at the source of the cancer pain and may enhance a patient's function, longevity, and comfort. Adjuvant therapies include nonopioids that confer analgesic effects in certain medical conditions but primarily treat conditions that do not involve pain. Nonopioid medications (over-the-counter agents) are useful in the management of mild to moderate pain, and their continuation through step 3 of the WHO ladder is an option after weighing a drug's risks and benefits in individual patients. Symptomatic treatment of severe cancer pain should begin with an opioid, regardless of the mechanism of the pain. They are very effective analgesics, titrate easily, and offer a favorable risk/benefit ratio. Cancer pain remains inadequately controlled despite the diagnostic and therapeutic means of ensuring that patients feel comfortable during their illness. Therefore, all practitioners need to make control of cancer pain a professional duty, even if they can only use the most basic and least expensive analgesic medications, such as morphine, codeine, and acetaminophen, to reduce human suffering.

Évaluation de la prise de décision de prescription d’un antalgique en prise quotidienne unique ou multiple dans les rachialgies aiguës

Decisions about treatment prescriptions depend on many factors. For example, the choice of once-daily or multiple administration of an analgesic, an aspect that is not determined by guidelines, depends essentially on medical practice habits, patient preferences, or both. We analyzed this treatment decision for acute back pain in a case-control study. A case-control study was conducted in metropolitan France between October and December 2005 among outpatients seeing general practitioners and specialists for acute back pain (cervical, thoracic, lumbar and low back pain). We compared the group treated by a once-daily analgesic (tramadol) with those treated by analgesics (WHO analgesic ladder steps 1 and 2) administered twice daily or more. Patients and physicians were questioned about the different supposed determinants of the treatment choice for acute back pain. Patients for whom physicians prescribed a once-daily analgesic had a history of back pain and previous prescriptions for other analgesics more frequently than the other patients, experienced significantly greater pain and more marked disability. The time to recovery estimated by the physicians was shorter for these patients, as was the time to return to work, estimated by patients. Treatment choice was also guided by the patient's choices: the once-daily analgesic was reserved for patients who prefer to take drugs to prevent pain and prefer a single dose daily. The choice of type of analgesic treatment for acute back pain depends not only on clinical condition (pain and disability), but also on clinical history, the future as envisioned by the physician and the patient's desires. Action to improve treatment choices must integrate these factors, especially as part of an overall education in therapeutics.

Management of Breakthrough Pain in Patients with Cancer

Breakthrough pain (BTP) in patients with cancer lacks a consensus definition and is subsequently inadequately diagnosed and assessed, therefore making it more challenging to manage. Cancer pain is generally moderate to severe in intensity and persistent in nature. Despite the problematic definition of BTP, it is generally described as having similar intensity, but may also be transitory and variable in predictability. Most breakthrough analgesia fails to be effective in the time required for BTP. No useful analgesia is therefore provided but drug adverse effects escalate. Cancer pain management relies on the WHO analgesic ladder. The frequency of BTP and its inadequate management means that it has significant adverse effects on patients, their families and those involved in their care. This article outlines a systematic, clinical and evidence-based approach to managing BTP in patients with cancer that emphasizes a holistic approach and an understanding of multidimensional 'total pain'. Guidelines for managing BTP are presented and areas of developing research are identified.

Opioid Use in the Philippines – 20 years after the introduction of the WHO analgesic ladder

Aim To find out if the opioid usage has improved in the Philippines 20 years after the introduction of the WHO analgesic ladder. Background Twenty years after the introduction of the WHO analgesic ladder in the Philippines, usage of morphine for cancer pain relief is still low. Barriers to opioid prescribing persist because of factors attributable to physicians, patients, families and constraints imposed by government regulatory bodies. Methods A survey of 211 physicians on a purposive sampling representing various regions in the country was done. Respondents included anesthesiologists, surgeons, oncologists, and palliative care specialists, who were expected to prescribe opioids in their practice. A 20-item multiple-choice questionnaire was developed to explore possible barriers to opioid prescribing. Results There is a very good awareness of the WHO analgesic ladder (72%) as well as the availability of opioids in their areas of practice (89.57%). Monitoring of pain as the “fifth vital sign” is adhered to by 68.25% of the respondents. There was only 60.66% compliance regarding availment of a narcotics license among respondent physicians. Various reasons were identified as to why they failed to get a narcotics license. Conclusions There was adequate knowledge about the WHO analgesic ladder among the respondents. There is a perceived resistance to prescribe strong opioids like morphine making the step 2 of the ladder as a comfort zone by the physicians who tend to “overstay” in this step. Government regulatory policies have affected the physicians' attitudes concerning narcotics license application. There is a very slow, though steady increase in morphine and oxycodone usage in the country. Barriers to opioid use in cancer pain management still persist twenty years after the introduction of the WHO analgesic ladder.

Proposed 5-step World Health Organization analgesic and side effect ladder

The WHO analgesic ladder has, up to now, been the “gold standard” for pain management. The ladder focuses on the presence or absence of pain relief but, at present, does not take into account the intolerable side effects of opioids. We believe that debilitating side effects are an equally valid reason for changing analgesia, particularly in light of new evidence supporting 'opioid switching'. Opioid switching involves changing a patient's strong opioid to an alternative strong opioid with the aim of improving analgesic response and/or reducing adverse side effects. We propose adding two additional steps to the WHO analgesic ladder to build an alternative five step ladder. The proposed fourth step involves 'opioid switching' and includes both pain and side effects as criteria for switching analgesics. The evidence for Step IV uses an algorithm derived from analysis of intervention patterns based on our recent trial data to identify the point at which a change in management is indicated. In our prospective study we identified four main factors which predict the need to switch. Three out of the four factors are opioid-induced side effects. Thus, once a strong opioid has been commenced (Step 3) and a patient has had an adequate trial of titration on their first-line strong opioid, the need for opioid switching (Step 4) is identified in the clinical setting once side effect scores fall within a critical range, triggering a change of treatment. If switching opioids fails, we propose that the fifth and final step of the WHO analgesic ladder should involve anaesthetic intervention.

Advances in the therapy of cancer pain: from novel experimental models to evidence-based treatments

Cancer related pain may be due to the malignant disease itself, or subsequent to treatments, such as surgery, chemotherapy or radiation therapy. The pathophysiology of pain due to cancer may be complex and include a variety of nociceptive, inflammatory, and neuropathic mechanisms. Despite modern advances in pharmacotherapy, cancer pain remains overall under-treated in a world-wide scale, and a main reason is lack of understanding of its pertinent pathophysiology and basic pharmacology. Recently, pertinent animal models have facilitated understanding of the pathobiology and have advanced the pharmacology of cancer pain, with significant translational applicability to clinical practice. Furthermore, quantitative and qualitative systematic reviews, integrating the best available evidence, indicate the validity of treatments that fit into an expanded view of the WHO-analgesic ladder. Appropriate current treatments include a valid therapeutic role of non-opioid and opioid analgesics, adjuvants -such as gabapentin, biphosphonates, palliative radiation therapy and radiopharmaceutical compounds, and interventional pain therapy (including neuraxial drug infusion and verterbroplasty for spine metastases) in selected patients. Overall, experimental animal models simulating cancer pain have been useful in providing pertinent information on the pathophysiology of cancer pain, and provide a testing ground for established and novel therapies, which are validated by clinical evidence. This is clinically significant, considering the epidemiological dimensions and the problematic nature of cancer pain.

Epidemiology and Characteristics of Pain in Blood-Related Disorders: A Longitudinal Study on Italian Adult Hospitalized Patients.

Background. In order to investigate the epidemiologic features of pain experienced by hospitalized patients with blood-related diseases, a six months longitudinal study on a consecutive cohort of adult patients has been conducted in four Italian Hospitals.Patients and Methods. There were 471 patients (221 male) with a median age of 67 (17–89) years. In the event of pain, each pain syndrome (PS) was properly assessed and the pain intensity was reported by a Numerical Analogue Scale (NRS), which rated from 0 (no pain) to 10 (the most severe), or, in less complaint patients, by a verbal description. A treatment approach based on the cancer pain WHO analgesic ladder was recommended.results. Data on distribution of patients according to the diagnosis and the relative incidence of pain are shown in table 1. Overall, of 471 patients, 175 (37 %) experienced almost one PS for a total of 245. In particular, 112 (64 %), 56 (35.6 %) and 7 (0.4%) presented 1, 2 and 3 distinct PS respectively. Among the 399 patients with malignancies, 165 (41.4%) presented 235 (96%) of the 245 diagnosed PS. Moreover, out of 175 patients who complained pain, 106 (60%) were in advanced phase of disease and collectively accounted for 179/245 (73%) PS. The pathophisiology of the 245 PS was diagnosed as follows: 121 (49 %) deep somatic, deriving from the bone in most cases, 51 (21 %) superficial somatic (mucositis and cutis derangements), and 35 (14 %) visceral, 24 (10 %) neuropathic, 14 (6 %) mixed or by unknown mechanisms. Out of the 35 visceral PS, 28 (80%) were complained by non-Hodgkin's lymphomas patients. The median pain intensity, according to NRS score was 6 (2–10). The adopted treatment approach, integrating causal interventions and analgesic measures, based on the institutional policy and guidelines of each centre, allowed an effective control of pain (reduction of NRS score of almost 50% within 24 hours) in 225/245 (92%) of the PS. No serious adverse effects were recorded.Conclusion. Our findings indicate that in the setting of haematological wards:pain is a significant symptom requiring prompt medical attention and a regular monitoring as the fifth vital sign;most PS can be effectively controlled by the currently available not invasive treatment strategies;the implementation of clinical pathways and standardized protocols based on well-defined algorithms can provide the auspicial advancements toward a “pain-free” haematological hospital.Table 1Study results: incidence of pain and distribution of the pain syndromes according to the hematologic diagnosis.DiseaseTotal Patients (%)Patients with pain (Pain Incidence %)Pain Syndromes (% of the total)NHL141 (30)56/141 (40)85 (34)AML104 (22)35/104 (34)47 (19)MM48 (10)39/48 (81)49 (20)ALL32 (7)15/32 (47)26 (11)LPD34 (8)8/34 (23)12 (5)MDS36 (8)12/36 (33)16 (7)NMD72 (15)10/72 (14)10 (4)Total471 (100)175/471(37)245 (100)NHL: Non-Hodgkin's Lymphoma; AML: Acute Myeloblastic Leukemia; MM: Multiple Myeloma; ALL: Acute Lymphoblastic Leucemia; LPD: others Lymphoproliferative Disorders; MDS: Myelodisplastyc Sindromes; NMD: Non-Malignant Diseases.