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Pain Control and the World Health Organization Analgesic Ladder

Robert Twycross, MA, DM, FRCP; Norelle Lickiss, MD, FRACP, FRCPE
JAMA. 1996;275(11):835. doi:10.1001/jama.1996.03530350017013.
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To the Editor.  —Like many others, we welcome the increasingly systematic approach to therapeutic review articles. We wonder, however, whether there is need for a code of practice to govern the publication of systematic reviews. Thus, while we cannot argue with the presentation of data from eight studies in the article by Drs Jadad and Browman,1 we are disturbed by the tone and content of the commentary.In our opinion, the authors have made a fundamental error in calling for a randomized controlled trial of a concept (the WHO three-step analgesic ladder). Indeed, it has already been demonstrated in Canada that it is difficult to evaluate the broader concept of palliative care.1 Thus, to say that randomized controlled trials of the three-step analgesic ladder are necessary before we can say that it has improved the management of cancer pain is naive and irrelevant. In all areas of clinical


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