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Cancer pain – strong opioids direct — RACP Paediatrics MCQ

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ModerateNeurologyCancer pain – strong opioids directRACP Paediatrics

A 10-year-old with metastatic osteosarcoma is receiving palliative chemotherapy. She has severe cancer-related pain not controlled by regular paracetamol and ibuprofen. Per the WHO analgesic ladder for children, what is the appropriate next pharmacological step?

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Correct answer: E — Palliative care alongside curative treatment

The WHO revised 2-step analgesic approach for children recommends stepping directly from non-opioids (paracetamol, NSAIDs) to strong opioids (morphine) for moderate-severe pain, skipping the weak opioid step (codeine). Morphine is the first-line strong opioid. Codeine is NOT recommended in children <12 years due to unpredictable CYP2D6 metabolism.

Reference: WHO – 2012 – Guidelines on Pharmacological Treatment of Persisting Pain in Children; RCH Melbourne – 2025 – Palliative Care Guidelines