Adopted by the 42nd World Medical Assembly
Rancho Mirage, CA., USA, October 1990
and rescinded at the WMA General Assembly,
Pilanesberg, South Africa, 2006
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.
- Treatment must be individualized to satisfy the patient's
needs and keep him or her as comfortable as possible;
- It must be understood that the needs of the patient with
chronic pain often differ from those of patients with acute
pain.
- 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.
- 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.
- 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.
- 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.
- 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.
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