A BETTER WAY TO LEAVE THIS WORLD

DYING cancer patients often suffer needless pain, a large-scale Italian
trial suggests. Doctors in Sicily have demonstrated that a step-by-step
plan for pain relief advocated by the WHO more than a decade ago achieves
rapid, lasting pain relief for the dying, with few problems.

In 1986, the WHO recommended that dying cancer patients be put first on
non-steroid painkillers such as aspirin, then mild opiates such as codeine,
then strong ones such as morphine, with the level at which they enter the
plan determined purely by their degree of pain. But Sebastiano Mercadente
of the Fatebenefratelli Hospital in Palermo says that these recommendations
are often ignored, because doctors are reluctant to administer morphine
(see "Give a drug a bad name . . .", New Scientist, 6 April 1996, p 14).

The WHO scheme has never before been tested in a large clinical trial in
which patients were followed until they died. In the nine-year trial, the
Sicilian researchers followed 3557 patients who were sent home to die, but
given painkillers as the WHO recommends. Nearly half had debilitating pain
at the start of the trial, but after the first week only 21 per cent did.
In their last week of life, only 1 per cent of patients had severe pain
(Cancer, vol 85, p 1849). A study of conventional cancer treatment in Italy
in 1996 found 24 per cent of patients dying at home had severe pain at the
end.

The Sicilian patients moved rapidly to opiates, with 16 per cent on
morphine after the first week and 35 per cent by the time they died. But
side effects were minimal, and patients did not appear to develop tolerance
to the drug. "The results are impressive," says Janet Abrahm of the
University of Pennsylvania.