Cancer pain - all change please?

Managing cancer-related pain remains a major clinical challenge, particularly in the context of increasing concerns around opioid use. The World Health Organization (WHO)'s analgesic ladder, a widely used framework for cancer pain management, is being re-evaluated - especially the second step involving weak opioids such as codeine and tramadol. Evidence suggests that these offer limited benefit and more side effects compared to initiating treatment with strong opioids. As cancer care advances, more patients live longer with chronic pain, requiring a tailored, multimodal approach. Meanwhile, the global opioid crisis has led to heightened regulatory scrutiny, making prescribers more cautious and potentially contributing to the under-treatment of pain. Long-term opioid use is also associated with risks including cognitive impairment, opioid-induced hyperalgesia and endocrine dysfunction. This review examines the ongoing relevance and limitations of the WHO ladder, highlights the challenges of opioid toxicity, and advocates for a personalised, multidisciplinary strategy to deliver safe, effective and compassionate cancer pain relief.