WHO recommendations for treatment of tumor pain. Development of an evaluation system

Aim of the study: Evaluation of the observance of the World Health Organiza tion guidelines for cancer pain management is a prerequisite for further re search into the effectiveness and acceptability of the guidelines. Methods: In a nationwide survey 172 physicians in pain management and oncol ogical units documented transdermal therapy with fentanyl. From October 199 6 to May 1997, 591 patients were included. A total of 148 patients had alre ady received transdermal fentanyl before inclusion in the survey, and no da ta on previous analgesic management were available for 7 patients. For 436 patients analgesic therapy before initiation of transdermal fentanyl was ev aluated. The last analgesic regimen documented by the treating physician wa s rated by three physicians from our pain clinic independently of each othe r. A raring system with four items (potency of analgesic according to the a nalgesic ladder of the WHO guidelines, prescription of a rescue medication, combination of nonopioids with opioids, inadequate combinations of analges ics) and a global rating (the analgesic regimen is considered adequate, suf ficient or inadequate) was used. Results: Good agreement was reached for cl assification according to the analgesic ladder, prescription of rescue medi cation and for inadequate drug combinations. The ratings on combinations wi th nonopioids showed more differences. The scores for the global assessment showed a wide difference between raters, with agreement on the same score for only 36.2% (raters 1 and 3), 36.7% (raters 2 and 3) and 55.5% of the pa tients (raters 1 and 3). Conclusions: A global assessment score is not useful for evaluation of guid eline acceptance. A more differentiated scoring system was developed for fu rther studies that includes the analgesic ladder and other aspects of the W HO guidelines in a 10-point score.