Approaching cancer pain relief

Pain is defined as an unpleasant experience—it is subjective and achieving pain relief is achieving a change in the patient's experience. There needs to be an adequate concept of a human person (an ecological model will be discussed) and a logical process for approaching pain relief in an individual patient (e.g. the plan used in the Sydney Institute of Palliative Medicine). Communication with the patient is critical to get a grasp of him or her as a person, their environment, personal experience and cultural background. Then encourage him or her to tell the story of the cancer saga as they perceive it, listening carefully for the matters which may have given rise to acute distress (for example, delay in diagnosis) and how they adjusted to this. The individual is conveying a great deal about him or herself as they tell their story. Next the story of the treatment and their experience of it, and then the response of their tumour to it—then the story of their pain: when it began, its characteristics, how it evolved, what factors worsen the pain, what relieves it, etc. This is followed by careful clinical examination to clarify what could be the most likely mechanism(s) responsible for the noxious stimulus. Some investigation (e.g. X‐ray) may be justified to assist clarification—but not before making a clinical diagnosis (best guess) and commencing treatment with drugs or other logical measures with some local action—depending on the most probable mechanism. Paracetamol/non‐steroidal anti‐inflammatory drugs (NSAIDs) etc may be logical. Threshold factors should be attended to—comfort, concern always, or anxiolytic or antidepressant drugs if the patient is pathologically anxious or depressed. The opioid drugs—with morphine still as the gold standard—should be appropriately used. This involves careful calibration of dose (below sedative level) normally with an immediate‐release, preparation—and, in the case of morphine, specific counselling concerning ‘myths’ to ventilate fears of dying, fears of addiction, fear of tolerance etc. It is irresponsible to use an opioid without assessing the prior state of the bowel (? loaded) or without prescribing a laxative. When neuropathic pain does not respond to a correctly calibrated opioid, it may be necessary to add certain antidepressants, anticonvulsants, gabapentin, steroid etc. A system must be set in place for evaluation of pain relief: relief is usually possible.