In order to effectively manage cancer pain, it is important to recognise that pain can arise from different origins. 

 

• The theory of total pain was developed by Dame Ciciley Saunders. This involved the recognition that pain is a result of a combination of physical, spiritual, psychological and social factors.

 

• Therefore treatment aimed at relieving pain should adopt a multidisciplinary approach. This involves reduction of fear, ensuring spiritual and social needs are met and management of physical causes of pain. 

 

 

 

 

 

 

 

 

 

 

 

Pharmacological management:

 

The analgesic ladder was devised by the World Health Organisation (WHO) and consists of a flexible three step process in the management of pain. 

 

The ladder follows a step wise approach, starting at step 1 with the use of a non-opioid

(paracetamol or aspirin) for mild pain and if there is inadequate relief then an adjuvant

analgesic (NSAID, anticovulsants, tricyclic antidepressants, biphosphonates or

dexamethasone) can be added according to the indication. However, this does not imply

that it is mandatory to start on the first step; the step chosen is based on the severity of the

pain. If step 1 does not provide adequate analgesia, then the prescriber can

progress on to step 2.

 

Step 2 involves the incorporation of opioid for moderate pain (tramadol, codeine or

buprenorphine) into the drug regimen along with the drugs used in step 1. This means that

opioid, non opioid and an adjuvant analgesic is used.

 

Step 3 is essentially the same as step 2, however the opioid employed is more potent

(morphine, diamorphine, oxycodone, hydromorphone, fentanyl or methadone). Morphine is

the opioid of choice in severe pain.