On average, a GP will care for about three patients dying of cancer at home each year. All patients, their carers and relatives fear pain. Two-thirds of patients will experience cancer-related pain, and in the vast majority of cases1 the pain can be effectively controlled. To instil confidence in patients and their carers, pain needs to be controlled quickly.
The SIGN Guidelines for the Control of Pain in Patients with Cancer2 are an important step forward. The document contains clear evidence-based guidance that, if followed, will ensure that pain is addressed effectively. They give clear directions on how to respond to pain in cancer patients, and suggest a logical and progressive approach that cannot fail to help optimise pain relief. More than 30 good practice points support the recommendations. The Quick Reference Guide should be an essential addition to all doctors' bags.
Although evidenced-based guidelines offer GPs the best chance of dealing with pain effectively, most cancer patients are managed by a multidisciplinary team working across many care settings. These include other doctors within the practice, primary care nurses, emergency out-of-hours staff, A&E departments, hospital wards, oncology centres and specialist palliative care services in hospital, community and hospice settings.
It is essential to gain a consensus on the guidelines being applied, from all those involved in the patient's care. It is consistent advice and effective action, as well as good clinical practice, that instil confidence in patients and carers. Any guidelines in use across a district must be available to all members of the team.
The guidelines emphasise that the effective and efficient use of appropriate analgesics, including strong opiates, must continue to make a major contribution to the care of cancer patients. The evidence for the efficacy of opiates and the need to use these drugs earlier to gain control of severe cancer pain is helpful advice.
Professionals in primary care need to regain their confidence in the use of these drugs. In a climate forever altered by Dr Harold Shipman,acceptance of opiate use by patients and carers is only going to be achieved if those advocating it have a good evidence base. Opiate use must be seen to be safe, with the rationale for the use of opiates clearly understood and the beneficial effect on pain clearly shown.
The preferred route of choice for all analgesics should be the oral one. Diamorphine should only be used when the opiate needs to be given subcutaneously. Alternative opiates have a role, but their effective and safe use may require the advice of palliative care specialists. Regular monitoring and review of patients is essential to good pain control and could have been emphasised more strongly.
Although the guidelines suggest that antidepressants and antiepileptics may require increasing doses when used as co-analgesics, they do not specify how this should be done. Some of the excellent prescribing and pharmacological advice available in other publications3 could have been incorporated.
The guidelines could have shown more clearly how to convert principles into immediate clinical action. This is what the GP in the patient's home, in the middle of the night, needs. The concept within the guidelines of sudden severe pain being an emergency requiring the patient to be seen and assessed without delay is to be applauded.
If implemented across teams responsible for the care of cancer patients, these guidelines will without doubt facilitate effective pain relief. Cancer patients deserve to be pain free, and guidelines such as these can be helpful to doctors and benefit patients.
- Zech DF et al. Pain 1995; 61: 277-84.
- Control of Pain in Patients with Cancer. A National Clinical Guideline. SIGN Publication No. 44. Edinburgh: RCP, 2000.
- Twycross R et al. PCF1 Palliative Care Formulary. Abingdon: Radcliffe Medical Press, 1998.
See also 'SIGN guideline paves the way for better control of cancer pain' in this issue.