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GENERAL PRINCIPLES OF TREATMENT: CHRONIC PAIN
It is the treatment of chronic cancer-related pain which requires a different approach to that for other chronic pain or acute pain.
• The aim of treatment is the prompt relief of pain and prevention of its recurrence.
The principles involved in the treatment of chronic cancer-related pain are:

• thorough assessment
• good communication
• reassurance about pain relief
• discourage acceptance of pain
• encourage patient participation

Thorough assessment is fundamental to successful treatment. Assessment of the type of pain (e.g. neuropathic, bone) will assist in deciding which modalities of therapy or which analgesics are appropriate. Assessment of the stage of a patient's disease may provide information about the cause of pain and also indicate which therapeutic modalities are appropriate.
Good communication is essential for good pain control. The doctor needs to listen carefully to the patient's description and in turn provide a clear explanation of the cause of the pain, the treatment options, and their relative merits and potential side effects. Good communication with other members of the treatment team will ensure a coordinated approach to pain control.
Many patients believe cancer is inevitably associated with severe pain and that the pain is unrelievable. Patients must be reassured that their pain can and will be relieved, both immediately and on a continuing basis, and a positive attitude encouraged.
Acceptance of pain by patients should be actively discouraged. Allowing patients to participate in the management of their pain builds trust and improves co-operation and compliance with treatment.
The treatment of chronic cancer-related pain:

• is an integrated part of a multidisciplinary plan of total care
• should be appropriate to the stage of the patient's disease
• employs the appropriate treatment modality
• may involve multiple treatment modalities
• must be consistent, not variable
• requires continuity of care
• involves repeated reassessment

Pain cannot be treated in isolation and other psychosocial and spiritual aspects of suffering which cause or aggravate pain need to be assessed and treated for pain control to be successful. A multidisciplinary approach to the management of chronic pain is therefore a clinical necessity and the treatment of pain is an integrated part of the overall plan of total care.
The treatment of pain should be appropriate to the stage of the disease; treatment for an ambulant patient will differ from that for one who is bed-bound.
Treatment should be consistent and not variable. Repeated changing of analgesics or any unnecessary changes are to be avoided. The patient needs a clear picture of the planned therapy, including the likelihood of any necessary changes. Unexpected or sudden changes cause insecurity and may lead to a loss of confidence by the patient in the treatment team. Continuity of care is similarly important.
Repeated reassessment is necessary to monitor both efficacy and side effects of the treatment given and to make appropriate changes necessitated by disease progression.
The modalities of treatment available for chronic cancer-related pain are:

• treatment of the underlying cancer
• analgesics
• adjuvant analgesics
• neurostimulatory treatment
• anaesthetic, neurolytic and neurosurgical procedures
• physical therapy
• psychological therapy
• lifestyle modification
• treatment of other aspects of suffering which cause or aggravate pain — physical, psychological, social, cultural, spiritual

Different types of pain respond better to particular treatments, as is the case with radiotherapy for bone pain and the use of anticonvulsants for neuropathic pain. In practice, combinations of different modalities are often used. Modification of the underlying pathology causing pain, by treatment of the cancer itself, can be an effective means of pain control.
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