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Pain Control and the World Health Organization Analgesic Ladder-Reply

Alejandro R. Jadad, MD, DPhil; George P. Browman, MD, MSc, FRCPC
JAMA. 1996;275(11):836. doi:10.1001/jama.1996.03530350017015.
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In Reply.  —We welcome the opportunity to respond to Drs Reidenberg, Twycross, Lickiss, Ventafridda, and Stjernsward in relation to our article on the WHO analgesic ladder.None of the letters contradict our analysis of the published literature. The two major concerns are that we ignored the importance of the ladder as a political tool and that the benefits of the ladder are so obvious that rigorous randomized control trials are not needed.We endorse all efforts made by the WHO program to increase the availability and acceptability of opioids for the treatment of cancer pain throughout the world, and share Dr Reidenberg's concerns about the limited implementation of the ladder. The focus of our review, however, was not to evaluate the political utility of the ladder, but to assess the evidence on the effectiveness of the ladder when it is used.We acknowledge the difficulties in conducting rigorously controlled studies


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