20 Questions and Answers about Pain Relief

The main reason that many people support the legalisation of euthanasia is to prevent the termanilly ill from suffering pain.
  • Palliative care can usually eliminate pain from a person's last days.
  • Pain is not always the main reason for someone to request euthanaisa; quite often it has to do with depression.
  • Hospice care can often help fight depression, and allows the patient's family to be present in a comforting environment.
by Robert Twycross, an international authority on pain control in cancer.

I write because of public debate about pain relief in dying patients, whether it can always be achieved, or whether sometimes deliberate termination of life is the only solution to ending pain and suffering. I believe many people may be unnecessarily fearful of what might happen to them or to their loved ones.

Pain relief in advanced cancer and in the dying, has been my special study for over 20 years and remains part of my daily medical practice. Although people have other fears about the end of their lives, including loss of intellectual faculties and independence, I have confined my remarks to pain because it particularly strikes fear into many people.

1. Do all dying patients experience pain?

No, only about one in three. Although in cancer, the cause of death in 25% of the population, pain is more common. Even with cancer, however, pain occurs in no more than 75% of patients.

2. Can pain in recurrent, incurable cancer be relieved?

In a consensus document published in 1986 by the World Health Organisation, the following statements were made by an international group of experts:

  • cancer pain can and must be treated
  • drugs usually give good relief, provided the right drug is taken in the right dose at the right time intervals
  • for persistent pain, the drugs should be taken regularly 'by the clock' and not just 'as needed'
  • the key pain relief drugs (pain-killers, analgesics) are aspirin and the opium derivatives, codeine and morphine
  • morphine and morphine-like drugs are the mainstay of treatment for severe cancer pain. Morphine is simple to administer, is widely available and, when properly used, provides good pain relief in most patients.
The WHO document also stresses that it may be necessary to use a second drug with morphine to achieve adequate pain relief. This emphasizes that, although morphine is the mainstay of treatment, it is not the whole answer. Other symptoms may also need to be treated. In addition, most patients and families need the active support of a doctor and a nurse to achieve the best results.

3. What about non-drug treatments?

There are also important and are generally used in conjunction with pain-killers. The more important non-drug treatments are:
  • psychological support for the patient and family
  • limiting certain activities (if pain is made worse by them)
  • radiation therapy (particularly for pain in bones)
  • injections to deaden nerves ('nerve blocks').
Psychological treatments such as relaxation therapy are also helpful.

4. What about a final crescendo of pain?

There is no need for anyone to die in pain. Usually, the medication which has previously sufficed will be adequate during the final hours or days. Sometimes, however, it is necessary to increase the dose to maintain comfort at this time. A final crescendo of pain is not a feature when pain has previously been well-controlled. 

5. What happens if I cannot tolerate morphine?

Morphine causes a number of unwanted effects. Constipation, nausea and vomiting are the most common but can be controlled. Rarely, a patient experiences hallucinations or has other disturbing mental effects. Such feelings often pass off spontaneously, but they too can be treated.

It is important to emphasize, however, that a change from morphine to an alternative morphine-like drug is hardly ever necessary; used skilfully, morphine has an excellent track record.

6. If morphine is used too early, will its effect wear off in time?

If you need morphine you will be able to go on taking it with good effect for the rest of your life, whether this is months or years. It may be necessary, however, to increase the dose from time to time. The main reason for an increase in dose is progression of the disease, rather than the effect of the morphine wearing off. 

Studies show that the longer someone is on morphine therapy:
  • the rate at which the dose rises becomes slower
  • the intervals between dose-increases becomes longer
  • the chance that the dose will be reduced becomes greater
  • The chance of stopping morphine altogether is greater.
7. What about 'paradoxical pain'?

Paradoxical pain occurs on rare occasions when morphine is injected into the fluid which bathes the spinal cord (intrathecal morphine). Possibly because of an individual genetic factor, a morphine derivative which neutralizes the pain-killing effect of the morphine itself is produced in large quantities. This leads to the paradox of more morphine resulting in more pain. Published data indicate, however, that alternative morphine-like drugs, such as fentanyl and methadone, can be substituted successfully.

8. If I take morphine regularly, won't I become addicted?

No, you won't. Over the years, I have treated several thousand cancer patients with morphine. I have never had trouble stopping treatment because of 'addiction'. However, morphine should not be stopped abruptly. If morphine is no longer needed, the dose should be reduced step by step.

The reason for a gradual reduction in dose is because people who have taken morphine regularly for several weeks often develop 'physical dependence'. This is not the same as addiction (i.e. psychological dependence) but it does mean that, if morphine is stopped suddenly and completely, withdrawal symptoms develop.

9. Exactly how much pain relief is possible?

The WHO Method for Relief of Cancer Pain is derived in large part from the experience gained in British hospices. A number of centres have evaluated its use. Results from one major cancer centre are as follows: complete relief 86%, adequate relief 11%, poor relief 3%.

10. What do you mean by 'adequate relief'? Surely anything less than complete is inadequate?

In some patients, all the pain cannot be controlled all the time. But this does not mean the patient is left in agony. Using a series of questions about how much pain interferes with activities and enjoyment of life, it has been shown that, when pain is rated on a scale of 0-10 (i.e. no pain to worst possible pain), pain rated as 1-3 has little impact on either activity or enjoyment of life. Thus patients with 'adequate relief' may say, for example:

"I still have pain, but it doesn't worry me now."

"It's still there, but it's not what you'd call pain."

"I can get on with things and forget it now."

11. What about the patients in the 'poor relief' category?

Nonetheless, in a small number of patients, it may take several weeks to achieve satisfactory control and, in a very few, the combination of adequate relief with the patient remaining alert may never be achieved. Sometimes in these rare cases, because of associated mental distress, it may ultimately be necessary to administer heavy sedation which induces unconsciousness in order to secure a peaceful death, and doctors should have the courage to do this in collaboration with the close family and nurses (see 14 below).

12. Which pains do not respond to morphine?

There are some kinds of pain that are morphine-resistant. For example, movement-related pain (including arthritis) does not respond well to morphine alone. The use of an aspirin-like drug is generally a crucial part of the management of such pain. Even so, there may well be a variable amount of pain when moving about and physically active. Muscle spasm pain, seen in about 25% of terminally ill cancer patients, does not respond to morphine or other pain-killers. It is, however, relieved by massage, muscle relaxant drugs and, sometimes, by local anaesthetic injections into a muscle 'trigger point'.

13. What about nerve damage (neuropathic) pain?

Pain resulting from nerve damage (rather than from nerve stimulation or irritation) is generally poorly responsive to morphine. It does, however, usually respond well to an antidepressant (even though the patient is not depressed) and/or an anticonvulsant (even though the patient does not have epilepsy). In terminal cancer, a mixture of morphine and a local anaesthetic given by injection close to the spinal cord (epidurally) is now used increasingly to treat such pains in cancer which are resistant to antidepressants and anticonvulsants. Ketamine, a special kind of anaesthetic drug infused under the skin, provides an alternative approach. 

14. Which pains are the most difficult to control?

The hardest pains to control are those which the patient unconsciously uses physical pain to express anger, anxiety or fear. If the patient can be helped to recognize and express such negative emotions, a previously intractable pain will usually respond to pain-killers. Unfortunately, with some people - a very small number - the negative feelings remain locked inside and the pain becomes overwhelming. 

This is perhaps the most frequent reason for needing heavy sedation at the very end. If a doctor does not anticipate the problem it may be extremely difficult to achieve adequate sedation in a short space of time. I wish to stress that it is always possible to sedate dying patients adequately so that they sleep without pain until death comes, using a combination of morphine and one or more tranquillizers.

15. Is it legal for a doctor to prescribe heavy sedation to a dying patient?

Yes, if other avenues have been explored and failed, the doctor is left with no alternative in his quest for relief. In a famous case in the late 1950s, Lord Justice Devlin stated:

"A doctor who is aiding the dying does not have to calculate in minutes, or even in hours, and perhaps not in days or weeks, the effects upon a patient's life of the medicines he administers or else be in peril of a charge of murder."

16. Is it ever necessary for the doctor to break the law and deliberately kill the patient in order to achieve relief?

No, it is not. In the few extreme cases where there is intolerable intractable pain, it is possible, while maintaining the prime intent of relieving suffering (see 11 above), to achieve this even though at the cost of unconsciousness. This is both morally acceptable and within the law. If a doctor can achieve his goal within the law, then there is no reason to break the law.

17. Might it not be better if the law was changed to permit 'mercy-killing'?

Dr Pieter Admiraal, a leading advocate of voluntary euthanasia in the Netherlands, has stated that pain is never a legitimate reason for euthanasia because methods exist to relieve it. Further, there are many people who fear referral to a hospice because they are afraid that the use of pain-killers will hasten their death. Such people far outnumber the very few who consistently express a desire for euthanasia even when their pain is adequately controlled. 

In the Netherlands, where voluntary euthanasia is already practised, there is evidence of abuse - a movement from voluntary euthanasia to imposed euthanasia. In my opinion, maintaining the status quo is the only way to maintain patient trust and to avoid abuse.

18. What is the status quo?

The doctor has a twin obligation to preserve life and to relieve suffering. Clearly, when a terminally ill patient is close to death, preserving life is increasingly meaningless and the emphasis on relieving suffering and achieving the best possible quality of what remains becomes paramount. However, even here, the doctor is obliged to achieve the objective with minimum risk to the patient's life. This means that treatment to relieve pain and suffering which co-incidentally may bring forward the moment of death by a few hours or days is acceptable (the principle of double-effect) but administering a drug such as potassium or curare, whose primary action is to cause death, is not acceptable.

19. Talk about 'double effect' scares me. Does morphine always shorten a person's life?

No, hardly ever. For example, think of all the people who have had life-saving operations followed by morphine injections to relieve the post-operative pain. And in terminal cancer, when morphine has been used to relieve pain, it is general experience that people sleep better, eat better and are generally more active - because they are no longer suffering from the debilitating effect of chronic unrelieved severe pain. In the vast majority, morphine is life-enhancing and life-extending, not life-shortening.

20. I know of people who have died in great pain. Shouldn't euthanasia be permitted until all doctors are capable of controlling pain in all dying patients?

There are now hospices or similar facilities throughout the United Kingdom. In addition, all major hospitals have Pain Relief Units run by anaesthetists trained to give nerve blocks and to administer epidural drugs when ordinary pain-killers are not adequate. Patients and families should therefore insist on referral to a hospice or Pain Relief Unit if they are dissatisfied. The WHO stated recently:

"Now that a practicable alternative to death in pain exists, there should be concentrated efforts to implement programmes of palliative hospice care, rather than a yielding to pressure for legal euthanasia."

Robert Twycross is Macmillan Clinical Reader in Palliative Medicine, University of Oxford and Director of the World Health Organisation Collaborating Centre for Palliative Cancer Care. He is an international authority on pain control in cancer. Among his many publications is 'Oral Morphine: Information for Patients, Families and Friends' (Beaconsfield Publishers, Beaconsfield 1991).

Pain Management / Palliative Care
Hospice provides support and care for persons in the last phases of incurable diseases so that they may live as fully and comfortably as possible. Recognizing death as part of the normal process of living, hospice focuses on maintaining the quality of remaining life, neither hastening nor postponing the inevitable.

Hospice exists in the hope and belief that through appropriate care--and the promotion of a caring community sensitive to their needs--patients and their families may be free to attain a degree of mental and spiritual preparation for death that is satisfactory to them.

A hospice program provides comforting care to terminally-ill patients and supportive services to patients, their families, and significant others 24 hours a day, seven days a week, in both home and facility settings. Physical, social, emotional, and spiritual care are provided during the last stages of illness, the dying process, and bereavement by a medically directed interdisciplinary team consisting of patients, families, professionals, and volunteers.

The primary goal of hospice care is to manage or control pain and alleviate the fears most commonly associated for a person with a terminal illness. In fact, the patient is involved in the decision-making process for choosing how they would like to be treated for their pain. In the majority of cases, most medication is given orally to avoid the discomfort injections would cause the patients. Some of the fears hospice care addresses include:
  • fear of pain related to the illness
  • fear of becoming a burden to the family
  • fear of financing the cost of a terminal illness
The hospice team of doctors, nurses, psychologists, spiritual counselors, and volunteers provide such everyday support services as administering medication, lending equipment, shopping, cleaning, and running errands for the patient. The hospice staff can be reached 24 hours a day and will visit a patient when needed, whether night or day.