World Medical Association, Statement of Policy on the Care of Patients with Severe Chronic Pain in Terminal Illness (1990)

Adopted by the 42nd World Medical Assembly
Rancho Mirage, CA., USA, October 1990



PREFACE
The care of terminally ill patients with severe chronic pain should provide treatment that permits these patients to close their lives with dignity and purpose. Analgesics, both opioid and nonopioid, are available and when properly used, can provide effective relief of pain for most terminally ill patients. It is incumbent on the physician and on all others who care for the dying patient with severe chronic pain to understand clearly the dynamics of the pain experience, the clinical pharmacology of analgesics, and the needs of the patient, family and friends. It also is imperative that governments assure that medically necessary quantities of opioid analgesics are available for appropriate application in the management of severe chronic pain.

PRINCIPLES OF THE CLINICAL MANAGEMENT OF
SEVERE CHRONIC PAIN
When a patient is terminally ill, the physician must focus efforts on the relief of suffering. Pain is only one component of the patient's suffering. However, the impact that pain can have on a patient's life can range from tolerable discomfort to the production of a sense of crushing and exhausting defeat.

Clinical experience has demonstrated that, in general, it is not so much which opioid is used to achieve the relief of severe chronic pain in the terminally ill patient, rather it is the manner in which the drug is used that is critical.

It is imperative, however, that the physician distinguish between acute pain and pain that can be expected to be chronic, as this distinction can carry important implications for the use of opioid analgesics. The following are general principles that should guide the treatment of severe chronic pain particularly through the use of analgesic medication.
1. Treatment must be individualized to satisfy the patient's needs and keep him or her as comfortable as possible;
2. It must be understood that the needs of the patient with chronic pain often differ from those of patients with acute pain.
3. The physician must know the potency, duration of action and side effects of available analgesics to select the appropriate drug, as well as the dose, route, and schedule that will ensure delivery of optimum pain relief for the patient.
4. Combinations of opioid and nonopioid analgesics can provide greater relief of pain to patients in whom nonopioid analgesics are no longer sufficient. This can be achieved without producing a concomitantly greater potential for undesirable side effects.
5. The development of tolerance to the analgesic effects of an opioid agonist can be surmounted by switching the patient to an alternative opioid agonist. This is based on the lack of complete cross-tolerance among different opioid analgesics.
6. Iatrogenic dependence should not be considered a primary problem in treating the severe pain of neoplastic disease and must never be a reason to withhold strong analgesics from patients who may benefit from them.
7. Governments should examine the extent to which their health care systems and laws and regulations permit the use of opioids for medical purposes, identify possible impediments to such use and develop plans of action to facilitate the supply and availability of opioids for all appropriate medical indications.