Introduction: The treatment of pain in cancer patients following the guidelines outlined by World Health Organisation has been found to be feasible and effective. The guidelines recommend a sequential three-step analgesic ladder for treatment of pain but there is a lack of conclusive data regarding the management of moderate pain with step II weak opioids or low-dose step III strong opioids.

Methods: In total, Eighty two adult patients with moderate cancer pain were included in this randomised controlled study to receive either low dose morphine or high dose tramadol. The primary outcome was the number of responder patients where the response was defined as patients with a 20% reduction in pain intensity on the numerical rating scale.

Results: The primary outcome occurred in 85.8% of the low-dose morphine and in 57.8% of the tramadol group (odds risk, 4.41; 95% CI,P<.001). The percentage of responder patients was found to be higher in the low-dose morphine group in this study. Clinically meaningful (>30%) and highly meaningful (>50%) pain reduction from baseline was significantly higher in the low-dose morphine group (P <.001). Due to inadequate analgesia a change in the treatment process occurred more frequently in the tramadol group. The general condition of patients, which was based on the Edmonton Symptom Assessment System (ESAS) overall symptom score, was better in the morphine group. Adverse effects were similar in both groups.
Conclusion: Moderate cancer pain can be managed significantly better by low dose morphine than tramadol with early onset of action and similar level of adverse effects.

Keywords: Moderate cancer pain, tramadol, morphine.

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