Adequate pain relief is archieved with a few simple
guidelines as recommended by the World Health Organisation. However, even
experienced pain management specialists report cases with inadequate pain
relief despite high personal and technical efforts.
While patients often suspect ineffective medications
or faults of the treating physician as the cause, physicians only to easily
will identify the patient as the source of the pain problem ('problematic
patient') or diagnose treatment resistent pain syndromes.
Therefore the first step with unreliefed cancer pain
should be the careful and critical identification of the problem. Disturbences
in the patient-physician-relationship may be relieved considerably if they are
recognized and discussed openly. The second step should be the identification
of an aim for the pain management that both physician and patient can agree to.
The aim of complete freedom from pain and restoration of the status before the
malignant disease often will not be realistic.
For patients with problematic pain that is resistant
to the prescribed analgesic medication the regimen should be reassessed
regarding obedience of the WHO recommendations: are analgesics,coanalgesics and
adjuvants used as indicated and taken as prescribed, are application times
appropriate, are further dose increases possible?
Treating cancer patients with opioids inadequate pain
relief in most cases is not related to high dosage, but to intolerable side
effects with low or medium dose ranges. Opioid switching is recommended for these patients, though
the level of evidence for this procedure is low. Other options are the
symptomatic treatment of side effects or invasive procedures if indicated.
Using all these options only few problematic pain syndromes remain. Some
typical situations may be identified. Patients with bone pain may report
adequate pain relief with rest, but intolerable pain with activity, and an
increase of opioid dosage may lead to oversedation with rest. Patients with
short exacerbations of pain may report inadequate pain relief as additional
doses of immediate-release preparations may not provide a fast enough onset. For
these situations treatment algorythms may be developed. Prerequisite for such
an algorythm is the interdisciplinary cooperation of an experienced palliative
care team with physicians, nurses and psychotherapeuts.