Principles of control of cancer painBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7548.1022 (Published 27 April 2006) Cite this as: BMJ 2006;332:1022
- Marie Fallon,
- Geoffrey Hanks,
- Nathan Cherny, director of cancer pain and palliative medicine
- Share Zedek Medical Centre, Jerusalem, Israel.
Pain is a complex phenomenon that is the subjective end point of a variety of physical and non-physical factors. For most patients, physical pain is only one of several symptoms of cancer. Relief of pain should therefore be seen as part of a comprehensive pattern of care encompassing the physical, psychological, social, and spiritual aspects of suffering. Physical aspects of pain cannot be treated in isolation from other aspects, nor can patients' anxieties be effectively addressed when patients are suffering physically. The various components must be addressed simultaneously.
Our understanding of the basic mechanisms of pain has improved considerably over the past few years. We now know that physical injury, pain pathways, and our emotional processing of this information are interlinked in the nervous system. Anxiety, fear, and sleeplessness feed into the limbic system and cortex. In turn, the brain talks back to the spinal cord modifying pain input at spinal levels. This then feeds back to the brain and a loop is established.
Mood disturbance is common in patients with uncontrolled cancer pain and may need specific management. Sometimes, however, mood will improve when the pain is resolved. Hence the first principle of managing cancer pain is a full assessment of the causes of all pain. With effective assessment and a systematic approach to the choice of analgesics using the World Health Organization's three step analgesic ladder, over 80% of cancer pain can be controlled with inexpensive drugs that can be self administered by mouth.
WHO analgesic ladder
The analgesic ladder remains the mainstay of our approach to analgesia, although …