Dr Anne Naysmith, consultant in palliative medicine, Pembridge palliative Care Centre, St Charles' Hospital, London

Following the WHO analgesic ladder will provide good pain control for the vast majority of patients who have pain during a terminal illness.1 Why then do we still fail to control pain in a significant proportion of such patients?

One possible reason is our failure to teach the principles of analgesia to doctors in training. Many doctors, as well as patients and their families, are anxious about using drugs such as morphine, fearing confusion, addiction or even shortening of life.

The Ethics Committee of the Royal College of Physicians was concerned that recent media coverage was likely to increase the anxiety of both doctors and patients about using strong opioids in the terminally ill.

First there was debate over euthanasia and the doctrine of 'double effect' (which often gives the impression that morphine in doses adequate to treat pain will always shorten life), and more recently Dr Harold Shipman's conviction. If these anxieties were to discourage doctors from prescribing adequately and appropriately, even more patients with terminal illness would be in danger of suffering uncontrolled pain.

The committee therefore asked a small working group, including two GPs, to bring together the principles of good analgesic practice in the form of a short, readily accessible guide. Although initially published by the Royal College of Physicians on 7 July 2000, both in printed form2 and on the College website (www.rcplondon.ac.uk), Pain Control has also been endorsed by the RCGP.

Pain Control covers six A4 sides in printed form and is written in a question and answer format. There is an initial brief discussion of some of the anxieties surrounding morphine use and an outline of the clinical features of the terminal phase of illness.

Although the care of dying patients is a fundamental part of primary care, doctors in training may rarely care for dying patients and young GPs entering practice may not feel confident that they can recognise the terminal phase.

The document then lays out the principles of the WHO analgesic ladder and deals in detail with initiation of morphine therapy, including titration of morphine dose against pain level.

The later section of the document covers the problems most commonly encountered when using opioid analgesia, such as pain that is poorly responsive to opioids and patients who have an intolerable level of side-effects when taking morphine and may benefit from switching to an alternative opioid.

The final paragraphs cover non-oral administration of opioids, particularly continuous subcutaneous infusion of analgesia using a syringe driver.

Everything to do with pain control can be found in standard textbooks, but few busy GPs, faced with a clinical problem, have time to search through academic texts. Local guidelines on pain control have been developed in many areas, but are not universally available.

The strength of this publication is that it outlines the practical knowledge that working doctors need in a readily accessible form. If existing knowledge were put into practice in the care of every patient suffering pain in a terminal illness, the improvement in pain control would be far greater than any improvements likely to come from new drugs or methods of administration in the foreseeable future.

Pain control in each individual patient is a complex problem. There is no simple audit programme to determine whether Pain Control produces measurable improvements in patients' pain. But the accessibility and simple format of the document make it potentially very useful both for education and training in primary care, and as the basis for work on clinical governance in PCGs and PCTs.

  1. Zech, DFJ et al. Validation of World Health Organization guidelines for cancer pain relief. A 10-year prospective study. Pain 1995; 63: 65-76.
  2. Principles of pain control in palliative care for adults. J R Coll Physicians Lond 2000; 34: 350-2.

Guidelines in Practice, August/September 2000, Volume 3
© 2000 MGP Ltd
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