• 1. Pain is an experience. If you have a hangover and feel ill with headache, nausea and vomiting, although an unpleasant experience, you know you will feel better tomorrow as you vow never to drink alcohol again. However, if you have exactly the same symptoms but it is because you have a malignant brain tumour, the experience is very different and much more frightening.
• 2. Pain is subjective. We know this because the same noxious stimulus can produce vastly different pain behaviours and analgesic requirements in different people.

For the rest of this article, I will concentrate on pain in cancer patients as that is the most common cause of pain in palliative care patients.

• 1. 30-50% of all cancer patients receiving active therapy experience pain.
• 2. This increases to 60-90% in patients with advanced disease.
• 3. 80% of cancer patients have two or more pains.

• 1. 70% cancer related.
• 2. 15% treatment related.
• 3. 15% incidental.

Thus with all this in mind, what is the best way to approach pain management in palliative care? One approach is the 3-step analgesic ladder recommended by the World Health Organisation, which addresses the severity of pain but not the cause. A more practical model is 'the Stickman' model developed by Professor Lickiss, Sydney Institute of Palliative Medicine.

The benefit of this model is that it addresses the cause of pain as well as dictating a holistic approach to pain management. This is a simple 4-step approach:

This case highlights the need to treat the cause of the pain, rather than giving morphine as the panacea for palliative care patients.

The opposite case is generally true of palliative care patients, where anxiety, anger, depression, frustration etc, work to lower the pain threshold and so worsening the pain, which in turn is a reminder of the disease, which in turn worsens the depression and so on.

Often, simply acknowledging the problems and fears the patient has can be enough to give some relief. Occasionally the use of professional support such as social workers, counsellors, pastoral care workers may be required for ongoing support.

However, given that most palliative care patients are in the community, this support will often fall to the GP and community nurses. The downside for the GPs is generally lack of time to deal conclusively with such issues. The upside is that they may have cared for patients and their families for many years and therefore be well aware of and able to tackle psychosocial issues. In this situation, the community nurse can be an invaluable support person for the patient and family.

The use of drugs for emotional issues needs to be considered. Anxiolytics can be of great benefit without the concerns about addiction or tolerance for palliative care patients. Of course depression is a common feature in this patient group and can be quite difficult to diagnose because of crossed symptomology, eg. lack of appetite, low mood, asthenia, morbid thoughts, and so on. The difference between appropriate sadness and depression can be blurred. However, two distinguishing questions to ask are:

• 1. Are you depressed? Generally, depressed patients will say they are depressed, whereas sad patients will admit being sad, but deny being depressed.
• 2. Are you the person you used to be? A clinically depressed patient will generally say they are not.

Finally, the easiest way to raise patient threshold for pain is to make sure they are getting a good night's sleep. Having a progressive, incurable illness is a process of having your reserves stripped away. Be they reserves for dealing with pain, tiredness, stress, loss of autonomy, or whatever. Getting back a good night's sleep is often a simple way of restoring some of those reserves. In fact if you don't ask about sleep you have not completed the pain assessment.

In summary, using the Stickman model for pain assessment is holistic, inclusive and likely to keep you out of trouble. In the next article, the nitty gritty of opioid analgesics will be tackled.