Introduction

Pain is a subjective experience, influenced by physical, psychological, social, and spiritual factors. The concept of total pain acknowledges the importance of all these dimensions and that good pain relief is unlikely without attention to each aspect.

Pain and cancer are not synonymous: at least two thirds of patients experience pain at some time during the course of their illness, and most will need opioid analgesics.1

How should we manage cancer pain?

The aims of managing cancer pain are to2:

• Achieve a level of pain control that is acceptable to the patient

• Assess pain and evaluate the effectiveness of management promptly

• Be aware of the components of total pain

• Relieve pain at night, at rest, and on movement

• Provide patients and their carers with up to date information on using pain relieving drugs

• Support and encourage carers.

World Health Organization analgesic ladder

Most cancer related pain can be managed effectively using orally administered analgesics. Current pharmacotherapy is based on the WHO concept of an analgesic ladder.3 This involves a stepwise approach to the use of analgesic drugs. The ladder suggests that clinicians should start with a non-opioid and if pain is not controlled progress to a weak opioid and then to a strong opioid.

The WHO analgesic ladder, which has been extensively validated,4 5 is a framework of principles and allows flexibility in the …