Intended for healthcare professionals

Clinical Review

The role of opioids in cancer pain

BMJ 2005; 331 doi: (Published 06 October 2005) Cite this as: BMJ 2005;331:825
  1. Columba Quigley (, consultant in palliative medicine1
  1. 1 Cancer Centre, Hammersmith Hospital, London W12 0HZ

    Columba Quigley, as a specialist in palliative medicine, works in a hospital based support team. She also works with a community based palliative care team and in a hospice, where patients are admitted for terminal care, respite, and control of symptoms. Pain occurs often in patients with cancer, particularly those with advanced disease. In addition, pain is one of the most feared symptoms in people with a diagnosis of cancer. Using analgesics (particularly opioids) appropriately effectively controls cancer pain in most patients


    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 …

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