The misappropriation of the WHO analgesic ladder for painful chronic wounds: from repair to retirement?

What is it about?

In a recently published EWMA document on the holistic management of wound-related pain, the only recommendation regarding systemic drug therapy was to follow the WHO analgesic ladder. Since that ladder was developed to specifically address cancer pain, its application in the field of painful chronic wounds represents another case of misappropriation, as there was no evidence to support such a decision. There is still no evidence. Misappropriation carries risks. The first step of the ladder recommends nonsteroidal anti-inflammatory drugs, which act by inhibiting cyclooxygenase in the inflammatory focus. Therefore, the drug must reach the inflammatory focus. But most chronic wounds are ischemic in nature, and ischemia should at least partially prevent drugs from reaching the wound bed. Consequently, the risk-benefit would to be inadequate in ischemic wounds, but there is no evidence, since this topic has not been the subject of research either. Wound-related pain has been largely forgotten and, as a direct consequence, there is an unacceptable paucity of studies. It is time for a change.

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