One of the ‘feel-good’ medical success stories of the latter part of the 20th century was the establishment in Britain and subsequent global dissemination of the hospice movement. This emphasised the holistic nature of care of dying people, notably those affected by advanced cancer. High quality symptom control and in particular, the multidisciplinary management of cancer pain, became a byword for hospice care. It was in hospices where the more liberal use of morphine was experimented – literally, with Dr Robert Twycross conducting a pioneering randomised controlled trial of oral morphine versus oral diamorphine that helped to move the latter off prescription charts (although parenteral diamorphine has remained, uniquely, on the British formulary even now). By the time that the term ‘hospice care’ was being re-branded as ‘palliative care’ in the 1980s, the international community had recognised the need for a more unified approach to cancer pain and so the WHO cancer pain programme and its 3-step analgesic ladder was born.1 Its aim was to ensure that all patients with (advanced) cancer had access to oral morphine and that other, non-opioid (so-called ‘adjuvant’ drugs) should also be considered. With the ‘coming of age’ of the WHO programme into its twenties, the pain and palliative care literature has recently been awash with reviews of cancer pain management.2 With some exceptions, they have become increasingly critical and challenging of the original - deliberately simplistic - model in today's complex medical armamentarium. Commonly debated topics are – the necessity for three steps; the concentration on morphine as opposed to other newer opioids that were unavailable or underestimated back in the 1980s; the emphasis on oral or systemic analgesia and the corresponding reduction in use of interventional approaches; the focus on the end of life and lack of recognition of acute cancer pain and pain in survivors. The publication in early 2010 of the British Pain Society's document ‘Cancer Pain Management’, in collaboration with the Association for Palliative Medicine and the Royal College of General Practitioners, was therefore very timely, as it not only adds to the growing debate about the relevance of the WHO approach, but it also emphasises the basic mechanisms of cancer pain, the role of non-drug therapies including psychological and invasive interventions and cancer pain at all stages of the disease. Summaries from this comprehensive document are published in this edition of Review in Pain. The BPS is delighted that the entire document has also been published in the journal ‘Pain Medicine’ in two parts.3,4 This issue also contains a series of succinct articles on some of the challenging areas around the interface of malignant pain management and palliative care. These papers offer, like the BPS Cancer Pain Management document itself, evidence-based reviews of both drug and interventional analgesia, focusing on some of the more difficult scenarios facing palliative care and pain teams: breakthrough pain, the role of transdermal opioids, malignant spinal cord compression, and the place of interventional techniques near the end of life. Together these reviews and the BPS document comprise a fine addition to the global debate on the future of cancer pain.
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May 20, 2011
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