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128 Chapter 10
Starting point assumes pain is uncontrolled on WHO step 2 analgesic at full dose
(e.g. codeine 60 mg four times daily or tramadol 100 mg four times daily)
Using Immediate Release (IR) morphine Using Modied Release (MR) morphine
Note: In patients who are elderly, frail, or have renal impairment it
is often preferable to titrate with IR formulation with low starting
doses e.g. morphine sulfate IR liquid 2.5-5 mg 4-hourly
Stop WHO step 2 drug
Start morphine IR 5-10 mg 4-hourly
Also prescribe same dose “as required”
to be given maximum 2-hourly for
breakthrough pain
Stop WHO step 2 drug
Start morphine MR 15-20 mg 12-hourly
Also prescribe morphine IR 5-10 mg
“as required” to be given maximum
2-hourly for breakthrough pain
Review after 24 hours
If sedation or opioid toxicity, reduce dose
If pain controlled, continue same doses
and review again in 24 hours
If pain uncontrolled, add up previous 24
hours morphine use (both regular and as
required)
Recalculate 4-hourly requirement and
prescribe nearest practical dose; do not
increase by more than 50%
Change breakthrough dose to match
new 4-hourly dose
Review after 24 hours
If sedation or opioid toxicity, reduce dose
If pain controlled, continue same doses
and review again in 24 hours
If breakthrough pain medication has
been needed and was effective, increase
morphine MR dose by adding total of
breakthrough doses to 24-hourly MR
dose (then divide by 2 to get the new 12-
hourly morphine MR dose)
Do not increase dose by more than 50%
If pain uncontrolled by additional doses,
seek specialist advice
Adjust breakthrough dose to 1/6th new
total
Review after 24 hours
If pain controlled convert to MR
formulation
Add up total morphine use in 24 hours,
divide by 2 and prescribe nearest
practical dose of morphine MR 12 -hourly
Prescribe appropriate breakthrough dose
Arrange follow up
Review after 24 hours
Where pain controlled, continue same
dose
If pain not controlled seek advice
Arrange follow up
Figure 4 Commencing strong opioids.
Breakthrough Pain: Opioid Dose
It is crucial that all patient’s taking regular opioids have a
breakthrough opioid prescribed too. A task group of the
Association for Palliative Medicine of Great Britain and Ireland
reviewed this in 2009 [24] and the guidelines were more
recently affirmed in an international review of practice [45].
Twelve recommendations about strategies for approaching
the management of cancer-related breakthrough pain were
devised based on low-grade evidence. These included assess-
ing whether patients have breakthrough pain, that break-
through pain should be assessed, and that an individual
management strategy should be devised.
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Pain and Its Management 129
Classically using the same opioid for MR and IR use has
been recommended where possible (this is not possible
with opioid patches – see section on transdermal patches),
with the IR dose at 1/6th of the total daily regular dose.
However, effectiveness but also adverse effects related to
breakthrough doses should be closely reviewed and then
tailored to the patient.
More recently rapid-onset opioids (ROOs), namely
transmucosal fentanyls, have been introduced. These come
in a variety of formulations including sublingual tablets
and nasal sprays. They may be particularly helpful for short
duration pain (commonly incident pain) though more
evidence base is needed to fully understand their role.
Their use should only be initiated under specialist care.
Pharmacogenomics and Opioid Analgesia
While response to opioids in terms of analgesia and side
effects is quite predictable, individual response must be
considered too. The prime example is the already dis-
cussed response to codeine and CYP2D6 expression,
whereby a poor analgesic response to codeine suggests
poor conversion of the codeine prodrug to morphine.
Furthermore, a number of polymorphisms of the
µ-opioid receptor have been described, impacting on the
analgesic effects and adverse effects of opioids [46]. Such
polymorphisms are very rarely characterised in a clinical
setting, however, and when prescribing a strong opioid
morphine remains first choice (when renal function is
not grossly impaired).
Other Strong Opioids
While morphine is usually first choice, a number of
strong opioids are available. In general they have no
superiority in analgesic effect to morphine [43,47] but in
some patients a change of opioid (an “opioid switch”) is
indicated because of intolerable side effects from mor-
phine, by organ (mainly renal) impairment or some-
times, in the case of a switch to methadone, because of
suboptimal analgesic effect.
There is evidence for this individualised therapeutic
approach. Fewer patients report constipation for
example when taking fentanyl as opposed to morphine
[48]. Changing from morphine to oxycodone (or vice
versa) can give analgesic benefit to the around 30% of
people where the initial drug has been ineffective [43].
Since it seems people may respond differently to differ-
ent opioids it is most important that if a switch is made,
the patient is monitored closely to assess their individual
effects.
Different opioids have different potencies, and these
equivalences need to be used when calculating doses on
changing opioids. It is usual practice to reduce the opioid
dose by 25–50% when switching, though this reduction
may be less for patients in severe pain, and more for those
on very high doses [17]. Specialist advice is often needed in
consideration of “switching.”
Information about alternative opioids to morphine is
found in Table 8, dose equivalence between morphine and
other opioids is in Table 9, and equivalence between oral
and subcutaneous opioids is found in Table 10.
Box 6: Points to consider when starting
strong opioids
• Ensure patients have been given clear oral and written
instructions, and their understanding has been confirmed
• MR opioids should be instructed to be taken 12 hours
apart (for example, 0800 and 2000) rather than the less
precise instruction “twice daily”
• Clarify with the patient that regular opioids should still be
taken even if a dose of breakthrough medication has just
been used
• Ensure that a regular laxative has been prescribed and
that bowel habit is monitored
• Ensure that patients have a supply of anti
-
emetic for
regular or as required use for at least the first week on a
strong opioid
• Monitor closely for efficacy, adverse effects, and opioid
toxicity
Box 7: Considerations when titrating opi-
oids
• When increasing the total regular daily dose of strong
opioid, it is usual to do so by 30–50% (the equivalent of
2–3 “PRN” doses).
• It is not recommended to titrate with transdermal prepa-
rations when there is unstable pain.
• Always adjust the breakthrough dose if the regular dose is
changed (up or down).
• Do not use two or more MR opioid formulations at the
same time without specialist advice.
• If pain control deteriorates, a holistic pain assessment
should be carried out.
• If an intervention takes place that may change the pain
burden, such as a nerve block, the opioid dose may
require reduction to avoid intolerance and adverse
effects.
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130 Chapter 10
Table 8 Alternative strong opioids to morphine.
Opioid Formulations Characteristics/Comments
Oxycodone IR liquid and capsules, MR tablets,
injection
Similar properties to morphine. MR formulation should
not be used in severe renal impairment
Hydromorphone IR and MR capsules, injection Good oral option for patients with renal impairment
(though dose reductions needed)
Fentanyl Transdermal patches, transmucosal
lozenges, buccal and sublingual tablets,
nasal spray, injection
Potency often underestimated. Less constipating than
morphine. Patches not suitable for unstable pain requiring
rapid titration. Transmucosal formulations permit options
for rapid absorption, but this requires close supervision in
initial titration. Suitable in renal impairment
Buprenorphine Transdermal patches, sublingual tablets,
injection
Patches not suitable for unstable pain requiring rapid
titration. Low strength transdermal formulations provide
an option for less severe pain or for patients sensitive to
other strong opioids. Suitable in renal impairment.
Toxicity not reversed by standard doses of naloxone
(higher doses needed)
Alfentanil Injection Only available as an injection. Better given in a syringe
driver than on an as-required basis as short half-life.
Suitable in renal impairment
Diamorphine Injection No analgesic advantage over parenteral morphine but
more soluble and thus commonly used by infusion,
especially when high doses are needed. Compatible with
many drugs in SC infusion
Methadone Tablets, oral solution, injection Non
-
opioid receptor (NMDA) actions potentiate analgesic
action. Highly variable pharmacokinetics and
pharmacodynamics between individuals; hence, switching
from other opioids and titration should be managed by
specialists [48]
Table 9 Equivalence between morphine and other opioids. Note that these figures are a guide and this table follows recommen-
dations from the Faculty of Pain Medicine [49] and PCF7 [17] rather than the manufacturers’ stated ratios.
Opioid Dose Ratio Example of Converted Prescriptions (with No Dose Reduction)
Switching between oral formulations
Morphine: Oxycodone=1.5: 1 Morphine 15 mg=Oxycodone 10 mg
Morphine: Hydromorphone=5: 1 Morphine 30 mg=Hydromorphone 6 mg
Switching from oral to transdermal formulations
Morphine PO: Fentanyl TD=100: 1 Morphine MR 30 mg/24h=Fentanyl TD patch 12 mcg/h
Morphine MR 60 mg/24 h=Fentanyl TD patch 25 mcg/h
Morphine MR 120 mg/24 h=Fentanyl TD patch 50 mcg/h
Morphine PO: Buprenorphine TD=100: 1 Morphine MR 12 mg/24h=Buprenorphine 5 mcg/h
Morphine MR 24 mg/24h=Buprenorphine 10 mcg/h
Morphine MR 48 mg/24h=Buprenorphine 20 mcg/h
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Pain and Its Management 131
Transdermal Opioids
Currently the opioids fentanyl and buprenorphine are
available as patches. This route of administration can offer
specific advantages, though patches must be used in appro-
priate circumstances.
Opioid patches are indicated for opioid responsive pain
that is stable; they are more difficult to titrate when analgesia
requirements are escalating and so are not a good choice at
this time. A switch to one of these opioids may be consid-
ered for the reasons previously discussed, to try to improve
analgesia or to reduce adverse effects. A switch may also be
considered to fentanyl and buprenorphine as both are well
tolerated when kidney function is poor. Additionally, a
patch can be considered when there are challenges with the
oral route, such as impaired or painful swallowing due to
cancer or treatment of this, or problems with drug
absorption in the gut, such as malignant bowel obstruction
or gastric outlet obstruction. A patient may be keen to
switch to a patch to reduce their tablet burden; using a patch
for this reason may also aid compliance. Finally, a patch can
be considered where there are concerns about misuse or
diversion of tablets (though patches can still be abused).
Practicalities
Transdermal patches need to be applied to a clean, dry, and
flat and hairless area of skin. The back and upper outer
arms are common sites. It is good practice to “rotate” the
patch site, so that it is not recurrently applied to an
identical area of skin. Ensure a good seal between the patch
and the skin on application. Patients should avoid applying
heat to the patch, such as in a hot bath, as this can increase
the absorption rate (it is ok for patients to shower). When
removed, patched should be folded over, sticky sides
together, and disposed of safely such as in a sharps bin or
returned to a pharmacist.
Fentanyl patches are available in a number of different
strengths, but all patches are designed to be used for
72-hours. Occasionally a patient will experience an end of
dose deterioration of pain, in which case changing patches
48-hourly can be helpful. Lower strength buprenorphine
patches are changed every 7 days, with higher strength
patches lasting 96-hours; in practice, it is best to change
these twice weekly, on the same days of the week for clarity.
Patches should not be cut to try to achieve alternative
doses.
While it is ideal to use the same opioid for modified and
normal release purposes, this is more challenging when
using transdermal patches. It is usual to use IR morphine
in the first instance as the as required opioid alongside
transdermal patches, unless there are reasons to use alter-
natives (for example, severe renal impairment, when oxy-
codone may be used at low dose).
Initiating and Discontinuing Transdermal Patches
The practicalities of timings around changing opioids,
including transdermal patches, can be challenging. See
Table 10 Equivalence between oral opioids. Note that these figures are a guide and this table follows the PCF7 clinical recommenda-
tions [17] rather than the manufacturers’ stated ratios.
Opioid Dose Ratio Example of Converted Prescription (with No Dose Reduction)
Morphine PO: Morphine SC=2: 1 Morphine MR 30 mg PO 12 hourly=Morphine 30 mg/24 h through SC
infusion
Morphine PO: Diamorphine SC=3: 1 Morphine MR 30 mg PO 12 hourly=Diamorphine 20 mg/24 h through
SC infusion
Morphine PO: Oxycodone SC=2: 1 Morphine MR 30 mg PO 12 hourly=Oxycodone 30 mg/24 h through SC
infusion
Morphine PO: Hydromorphone SC=10: 1 Morphine MR 30 mg PO 12 hourly=Hydromorphone 4 mg/24 h through
SC infusion
Morphine PO: Alfentanil SC=30: 1 Morphine MR 30 mg PO 12 hourly=Alfentanil 2 mg/24 h through SC
infusion
Oxycodone PO: Oxycodone SC=1.5: 1 Oxycodone MR 20 mg PO 12 hourly=Oxycodone 25 mg/24 h through SC
infusion
Hydromorphone PO: Hydromorphone SC=2: 1 Hydromorphone MR 8 mg PO 12 hourly=Hydromorphone 8 mg/24 h
through SC infusion
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132 Chapter 10
Box 8 for guidance on this, remembering the importance
of individual assessment in each case. Box 8 also contains
guidance on the timings on switching opioids given by
routes other than transdermal patches.
When changing from an alternative opioid to trans-
dermal preparations, patients may experience an opioid
withdrawal-like syndrome, with gastric upset a predomi-
nant feature. Utilising doses of IR opioid will help these
symptoms [17].
Opioid Adverse Effects
It is important to counsel patients about the potential
adverse effects of opioids on commencement, to aid under-
standing and so that patients know what to expect. Adverse
effects occur with both weak and strong opioids.
Constipation is the commonest adverse effect of opi-
oids, occurring in up to 95% of cases. All patients taking
regular opioids should also take a stimulant laxative to
counteract this.
Nausea and vomiting is also common in those taking
opioids. This is much more likely during the first week of
treatment, or when the opioid dose is increased.
Metoclopramide or Haloperidol are appropriate anti-
emetics, and should be available for patients on an as
required basis during these times, being stepped up to reg-
ular if nausea or vomiting occurs.
A dry mouth is also a common effect of opioids. It is
worth reviewing the patient’s medications as a whole as
other offending medications may be discontinued. Local
oral measures can also be useful.
Other well-recognised adverse effects include drowsi-
ness, delirium, hallucinations and myoclonus. Sometimes
these effects can settle down within a few days. If halluci-
nations are problematic they may improve with a small
dose of haloperidol. If adverse effects remain problematic
and opioids have been at least partially effective, an opioid
switch should be considered.
Opioid toxicity occurs when opioids are escalated too
quickly for the individual patient, or when opioids are not
excreted as expected, such as in renal impairment. Earlier
features include drowsiness, confusion, and myoclonus,
later progressing onto respiratory depression. If opioid
toxicity is diagnosed opioids should be reduced, or tempo-
rarily stopped in more severe cases. Naloxone is only indi-
cated when the patient’s respiratory rate is less than 8
breaths/minute and/or the patient’s oxygen saturations are
below baseline (due to opioids). Please refer to local guide-
lines when treating opioid toxicity with respiratory
depression.
Fears and Concerns Related to Use of
Morphine and Other Opioids
Guidelines on the use of and literature about opioids are
freely available, though concerns remain relatively
common among both healthcare professionals and patients
(Box 9). Some fears may be related to the perception of
opioids as “recreational drugs,” while others are related to
the use of opioids by professionals; though important to
report on, events in the media such as the inquiry into
Box 8: Guidance on timings of changing
opioids. Guidance taken with permis-
sion from The North of England Cancer
Network Palliative and End-of-Life Care
Guidelines [50]
Oral to subcutaneous infusion
From IR opioid: start syringe driver immediately.
From 12-hourly MR opioid: start syringe driver 4 hours
before next oral dose due.
Subcutaneous infusion to oral
Switching to either IR or MR opioid, stop the syringe driver
and give first oral dose at the same time.
Oral to patch
From IR opioid: apply patch when convenient and use oral
IR opioid as required.
From twice daily MR opioid: apply patch at same time as last
dose of MR oral opioid.
Patch to oral
Remove patch 6 hours before giving first dose of oral MR
opioid.
For first 24 hours (i.e. first two doses) give HALF the calcu-
lated equivalent dose since the transdermal fentanyl will
take time to be cleared from plasma and subcutaneous
reservoir.
After 24 hours increase to the calculated equivalent dose if
clinically indicated by pain.
Patch to subcutaneous infusion
For those likely in the last days-short weeks of life, it is
reasonable to continue the patch and add a syringe driver
in addition to this, being careful to calculate the correct IR
opioid dose.
In other situations where a change from patch is required,
remove patch and start syringe driver 6 hours later using
HALF the calculated opioid equivalent dose for the first 24
hours then adjust according to symptoms.
Subcutaneous infusion to patch
Apply patch. Continue subcutaneous infusion for a fur-
ther 6 hours then discontinue syringe driver.
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Pain and Its Management 133
Gosport War Memorial Hospital [51] are understandably
concerning for patients and professionals alike.
Evidence and experience has shown that opioids, when
used in an appropriate way, are excellent analgesics that are
safe to prescribe. Fears around their use are unjustified
[52] and often unfounded. However, it is of critical impor-
tance in discussing patients’ fears about these medications,
to address anxiety and to help secure concordance of pain
management plans. Of particular importance is explaining
that addiction (psychological dependence) does not occur
when opioids are used for pain management in palliative
care, and that if pain is reduced by other means (e.g. nerve
blocks) then opioids can generally be reduced. Note, how-
ever, that opioids should be gradually reduced and not be
stopped suddenly as withdrawal symptoms can occur.
It is important for patients in the UK taking opioids to
know about driving legislation. Roadside drug tests were
introduced in 2015, and those taking prescribed opioids
should carry evidence of this (such as a prescription),
which will prevent prosecution as long as their driving is
not impaired [53].
Adjuvant Analgesics or Co-analgesics
Adjuvant analgesics are medications that were initially
designed for another indication, but also have an anal-
gesic benefit when given in the correct circumstances.
Many adjuvant analgesics are particularly useful in the
treatment of neuropathic pain. Note that the evidence
base for many of these medications may be in a different
setting, for example painful diabetic neuropathy rather
than cancer-related nerve pain for neuropathic drugs. It is
best practice to initially use one adjuvant analgesic and
titrate up the dose, though it is common to then introduce
a second analgesic that works synergistically. Medications
are discussed below with a summary in Table 11.
Anti-convulsants
These medications have been used for neuropathic pain
for a number of years, for example Carbamazepine for
trigeminal neuralgia. For other causes of neuropathic pain,
the gabapentinoids (gabapentin and pregabalin) should be
used first line [54]. These medications work via voltage-
gated calcium channels, helping reduce glutamate release.
They are often well tolerated if titrated at an appropriate
pace for the patient. The most common side effects are
drowsiness and dizziness. The dose should be reduced in
renal impairment [17]. Other anti-convulsants, such as
sodium valproate, may also be effective but should be used
under specialist supervision. Clonazepam is sometimes
used by specialists but as yet has very limited evidence base
for neuropathic pain.
Antidepressants
Medications in this group are the others recommend by
NICE as first-line for neuropathic pain [54]. Tricyclic anti-
depressants, particularly amitriptyline, are commonly
used, and have the lowest number needed to treat (NNT)
value for medications in neuropathic pain [55]. They have
a number of mechanisms of action, particularly through
noradrenaline re-uptake [17]. Doses should be started low
and titrated as required and tolerated. They are contra-
indicated in heart disease and in those with arrhythmias.
Adverse effects are commonly due to their anti-cholinergic
properties, including dry mouth, urinary retention, consti-
pation, and a risk of falls.
The other drug recommended by NICE is duloxetine, a
serotonin and noradrenaline reuptake inhibitor (SNRI),
for which most evidence is in diabetic neuropathy. The
most common side effects are drowsiness and a dry mouth.
Mirtazapine is also sometimes used for neuropathic pain
but has a very limited evidence base; the risk of serotonin
toxicity is lower with mirtazapine compared to other
antidepressants.
Corticosteroids
Corticosteroids have multiple indications in palliative
care, for which pain is one. They are most useful for liver
capsular pain and neuropathic pain (see case study in Box
10). They have anti-inflammatory effects, but also work
through reducing peri-tumoural oedema. Early side
Box 9: Professional and patient concerns
about opioids
Professional Patient
Patient addiction/
dependence
Addiction/dependence
Diversion of patient supply
to illegal use
Social stigma
Respiratory depression Side effects
Excess sedation/confusion/
cognitive impairment
Morphine equated to
imminent death
Fear of expediting death Pain will become resistant to
analgesia so “nothing left
when pain severe later”
Effect on functionality e.g.
driving
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134 Chapter 10
effects include gastric irritation and an increase in blood
glucose, particularly in those with pre-existing diabetes
mellitus, with later effects including proximal myopathy,
a decrease in bone density, and other metabolic effects. It
is best practice to review corticosteroids regularly,
reducing them to their lowest effective dose, and ideally
stopping after less than three weeks, to avoid the risk of
Addisonian effects and late side effects. As they work
quickly for nerve pain they are particularly useful to pre-
scribe whilst other more standard neuropathic agents are
being titrated.
Topical Analgesics
A number of agents are available as topical formulations.
Levomenthol 1–2% (in Aqueous Cream) is helpful for itch
through an effect on sensory nerve endings, but can also
be useful for the “stretching” pain experienced from oede-
matous limbs. Capsaicin cream works by reducing sub-
stance P production and can be helpful for localised
neuropathic pain, though it is an irritant and is best
applied with a gloved hand. The local anaesthetic lidocaine
is available in a medicated plaster, which is licensed for
post-herpetic neuralgia. It can be useful for localised neu-
ropathic pain though has a very limited evidence base.
Plasters are used in a 12 hour on, 12 hour off pattern, and
caution is advised in those with severe cardiac, renal, or
hepatic impairment [17].
Interventional Analgesia
Procedures for pain are considered in those whose pain
remains challenging despite specialist input and a trial of
pharmacological and non-pharmacological options. This
may be due to poorly responsive pain or intolerance to a
Box 10: Case study
“Mr. Talbot’s pain responded well to radiotherapy, cortico-
steroids, and neuropathic agents. His corticosteroids were
down-titrated. He later developed visceral abdominal pain
and morphine was appropriately titrated to allow adequate
analgesia that was well tolerated. Discussions about his pref-
erences for the future were supported and he was able to stay
in his preferred place of care of home.”
Table 11 Adjuvant analgesics.
Group Indication Example(s) with Maximum Dose Range
Antiepileptics Neuropathic pain Gabapentin 100 mg TDS – 1.2 g TDS
Pregabalin 25 mg BD – 300 mg BD
Antidepressants Neuropathic pain Amitriptyline 10–75 mg OD (nocte)
Duloxetine 30 – 120 mg/day
Corticosteroids Neuropathic pain
Liver capsular pain
Dexamethasone 6 – 12 mg daily initially, reducing every few
days to stop (within 2–3 weeks)
Bisphosphonates Bone pain (particularly in myeloma,
breast cancer and prostate cancer)
Zoledronic acid 4 mg in 100 ml 0.9% saline infused over 30
min given every 4 weeks
Benzodiazepines Muscle relaxant Diazepam 2–10 mg daily
Midazolam 2.5–5 mg SC per dose
Neuropathic pain Clonazepam 500 micrograms – 4 mg daily
Muscle relaxants Muscle spasm Baclofen 5 mg BD – 20 mg TDS
Anticholinergics Bladder spasm Tolterodine 2 mg BD
Colic (in complete bowel obstruction)
or rectal spasm
Hyoscine butylbromide 60–120 mg/24 h SC infusion
Ketamine (for use under
specialist initiation and
supervision only)
Neuropathic pain not responsive to
other medications
Starting dose: 10–25 mg PO QDS or 50–100 mg/24 h by SC
infusion
Usual maximum dose: 50–100 mg PO QDS or 500 mg/24 h by
SC infusion
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Pain and Its Management 135
number of analgesics. Such patients should always be
referred to specialist palliative care services, who can liaise
with interventional pain colleagues to consider neuraxial
options (epidural or intrathecal inteventions) and/or neu-
rolytic procedures (such as a coeliac plexus block or
cervical cordotomy).
Non-pharmacological Interventions
In the early part of this chapter, the importance of a whole-
person assessment was discussed. Pain is a complex
symptom that is generally multi-dimensional in the setting
of advanced illness. Management needs to reflect this. It is
therefore important that the multi-disciplinary team
(MDT) is involved in developing a management plan, and
treatments are considered from different professionals
within this group. This may include among other
specialists:
•
Physiotherapy and occupational therapy who may
support the use of a TENS machine, acupuncture, rehabil-
itation, and goal setting
•
Clinical psychology to explore psychological causes and
impacts of pain
•
A spiritual care team to support spiritual aspects of pain
•
Complimentary therapies as reducing anxiety, increasing
relaxation, and promoting self- efficacy such as through
hypnosis are all valuable pain management strategies
Additionally, it is important to consider the underlying
disease process and whether direct treatment for this will
help pain, for example:
• The use of radiotherapy for painful bony metastases
•
Surgical fixation of impending fractures from bony
metastases
• Vertebroplasty for osteoporotic spinal fractures
Finally, the value of communicating to patients about their
pain should not be underestimated, and there is evidence
that patient-based educational interventions support pain
management [56].
Conclusion
Pain is a complex, multi-dimensional symptom, particu-
larly in the context of advanced illness. A whole person
assessment and an individualised approach to management
will allow the best outcome for the patient. Pharmacological
approaches are very important, and clinicians should have
a good grasp of a number of medications that are likely to
be helpful in different circumstances. Clinicians should
also recognise when referral on to specialist services is
required for use of more complex analgesia, treatment of
the underlying illness, and input from the wider MDT for
non-pharmacological approaches.
Acknowledgement
Many thanks to Dr Alex Nicholson, previous author of this
chapter, who allowed me to use the structure of and images from
the previous edition in writing this chapter.
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