Introduction

In the international effort to provide better pain management around the world, it has been repeated in lectures and standard texts, that better pharmacological management and increased use of opioids in particular will go a long way to solving this problem. The “three-step analgesic ladder” has been promoted by the World Health Organization in its guidelines Cancer Pain Relief to enable healthcare providers to offer effective management. Reviews have often stated that this can be expected to provide effective analgesia in 70–95% of patients. Although this approach is not above criticism, lack of knowledge and restriction of opioid availability has continued to present barriers to effective pain management. Nevertheless knowledge of a basic approach to pharmacological management and access to opioids, still leaves a significant number of patients with difficult pain management problems. This is well illustrated by evidence that even though global consumption of opioids has increased dramatically, particularly in North America and Western European countries, this has not provided a complete solution. Over the last decade there have been numerous reports of toxicity associated with high opioid doses producing a constellation of problems including myoclonus, hallucinations, agitated delirium and seizures. These difficult pain management problems have resulted in a somewhat controversial discussion on the topic of neuropsychiatric toxicity and opioid rotation or sequential opioid trials.

The complexity of the human experience that may result in the failure of pharmacological management alone is recognized by both classic literature and more recent commentators: “It was true, as the doctor said that Ivan Ilych's physical sufferings were terrible, but worse than the physical sufferings were his mental sufferings, which were his chief torture.