Doctor, can't you ease the pain?

Thousands of cancer patients are suffering needlessly because of misplaced fears about the use of morphine. By Rita Carter

There is no good reason why any but a tiny fraction of cancer sufferers should end their days in agony. Yet they do. "Jonathan was literally crawling across the floor, sobbing, a couple of days before he died," says one woman who witnessed her husband's cruel end. He was suffering from cancer of the pancreas which had spread to the spine. "I adored him - but that night I went into the garden and screamed out to God to finish him off. The pain was just too much for him to bear."

Suffering like this is not unusual. One study found that 88 per cent of 2,000 recently deceased cancer patients in the UK experienced chronic pain in the months before they died, and much of it was severe. Throughout Europe the number suffering in this way at any one time is probably more than one million.

The most shocking thing about this pain is that practically all of it could be eliminated - and no expensive, hi-tech or invasive therapy would be required to do it. All it would take is the correct employment of one of the oldest medicines known to man.

Opium has been soothing the agonies of disease since the beginning of recorded history and its modern derivatives, the most common of which is morphine, can give near total pain relief in 90-95 per cent of cases. In the past 20 years, the use of opioids - in whatever quantities necessary to relieve pain - has been strongly and repeatedly recommended by agrowing body of experts in palliative medicine. Yet thousands of terminally ill patients do not get enough of them to keep their pain at bay.

"You may go to visit a patient who is cared for at home and find they are in agony," says Lucy Stewart, a MacMillan nurse. "When you ask what drugs they are on, you find the doctor has given them Distalgesic [for the relief of mild to moderate pain] or something. If a Macmillan nurse is called in, we can usually put things right, but heaven help those who slip through the net."

The reason many people do not get adequate pain relief is that many doctors, nurses, patients, their relatives and governments all share a misdirected and largely irrational fear of narcotics, the group of painkilling drugs derived from opium.

Morphine, given by injection or, more recently, slow-release tablet, is associated with imminent death, the murky world of illicit drug abuse and the moral and legal quicksands of euthanasia. Earlier this month it featured in a widely publicised "mercy killing" of an elderly woman dying of liver cancer. Morphine is wrongly believed to create automatic addiction, and to need constant upping of the dose in order to go on working.

Those who suffer most from this tangle of negative beliefs are the growing number of terminally ill patients, whether cared for by their GPs or in hospital.

Julia Addingtonhall, a psychologist at University College London, interviewed the relatives of 2,000 recently deceased cancer patients. "I heard of hospital patients having to go whole weekends in pain because the senior doctors were away and the junior staff did not have the knowledge or confidence to give out morphine," she says.

"Relatives told me how they begged the nurses to come and give their dying mother or father some pain-relieving drugs but were often turned down because hospital rules were too inflexible to allow it. One lot of nurses even refused to vary their route around the ward with the drugs trolley in order to speed things up."

The restrictions surrounding morphine use are largely based on the fear of creating addiction. "In fact, it is practically impossible to create addiction when morphine is used for analgesia," explains Dr Mike Harmer, a pain specialist at the University of Wales. "You can give huge amounts of it to a person in severe pain - 60 or 70 times the normal dose. Then, when the crisis is over, you can cut it out altogether and the patient trots off without a backward glance - no withdrawal symptoms at all."

This may seem extraordinary in the context of our "one shot and you're hooked" anti-drug propaganda. But it is not as contradictory as it sounds. One of the curious properties of narcotics is that they work quite differently on people who are in pain as opposed to those who use it for kicks.

Professor Patrick Wall of UCL, a pre-eminent pain specialist, believes that pain probably triggers changes in the brain's pain receptors which cause morphine to be "mopped up" in a way that doesn't happen normally. It also seems to protect against tolerance - the need constantly to increase the dose to get the same effect.

"Both doctors and patients often delay starting narcotics, despite intense pain, in order to `save' them for the very end," says Professor Wall. "In fact, there is no need to ration it in this way. With morphine, the level needed to get a `high' goes up, but the amount required to control pain stays steady. So if pain relief is what it is used for, there is no need to up the dose unless the pain gets worse."

So long as there is pain, morphine does not cause the respiratory depression that normally makes it so dangerous. Only when the drug continues to be given after the pain has been eliminated does it exert its potentially fatal side-effects. "It is really quite difficult to kill a person in severe pain with morphine," says Dr Harmer. "You would have to keep pumping the drug in way past the point at which they can feel nothing at all."

Even when doctors are not hampered by prejudice about narcotics, their patients often are. A 1994 Gallup poll found that one in two adults would not want to take opiates for pain relief, even if they badly needed them.

Dr Ilora Finlay, chairman of the Association of Palliative Medicine, says: "Patients often say, `I don't want to go on to morphine yet', meaning that they aren't ready to die yet. They have this idea that it is a drug which is only used right at the end. They may fear, too, that it will shorten their life because of reports about morphine being used in mercy killings. In fact, if morphine is used right, it is likely to lengthen their life because they will be under less stress once the pain is relieved, be able to eat better and take more interest in life."

Another common reason for patients' reluctance to take narcotics is the worry that they might end up doped to the eyeballs and no longer in control. One solution to this is to allow them to dispense their morphine themselves. Patient-controlled analgesia (PCA) allows the patient to self-administer drugs according to need by using a small button-activated device. PCA has revolutionised post-operative analgesia, but it is rarely used in terminal care, partly because each device costs about pounds 2,000.

"Hospital managements gauge their outcomes in terms of cures rather than quality of life, so pain relief still comes low on their list of priorities," says Dr Finlay. "Getting rid of the fear of the drug is important. People should realise that for a dying person there will always be a last injection, just as there will always be a last breakfast. But it won't be the cornflakes that kill them - and, used correctly, it won't be the morphine, either."

A new booklet, `Get on top of your pain', is available from 5 Theobalds Road, London WC1X 8SH. Please send an SAE.