Download Exploring the myths of morphine in cancer: views of the

Support Care Cancer
DOI 10.1007/s00520-014-2379-9
ORIGINAL ARTICLE
Exploring the myths of morphine in cancer: views of the general
practice population
Matthew Grant & Anna Ugalde & Platon Vafiadis &
Jennifer Philip
Received: 3 June 2014 / Accepted: 30 July 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Background Morphine is widely used in cancer care, and
understanding the concerns and perceptions of patients, family
and friends is vital to managing pain and distress effectively.
The ‘myths of morphine’ have frequently been discussed in
medical literature, yet the extent to which such views are held
is not clear. This qualitative project explores the perceptions
and attitudes of the wider community towards morphine use in
cancer care, to understand this ‘mythology’ according to those
who in the future may themselves require its use.
Methods Semi-structured interviews were held with patients
presenting to a metropolitan general practice clinic in
Melbourne, Australia. A grounded theory framework
underpinned the data collection and thematic analysis
undertaken.
Results Interviewees (15) were aged 24–81, with a variety of
experiences with cancer care and previous morphine use.
Interviewees were highly supportive of morphine use in cancer care, with this attitude founded on the perceived severity of
cancer pain and the powerful nature of morphine. They described a number of reasons morphine may be used in cancer
care: to treat pain, to enable peace and also as a treatment for
cancer.
Conclusion The public view of morphine to emerge from this
study is markedly different from that discussed in the myths of
morphine. It is viewed as a medication that has the ability to
provide peace and control both pain and the course of cancer.
The participants in this study described a wish for greater
M. Grant (*) : A. Ugalde : J. Philip
Centre for Palliative Care, 6 Gertrude St, Fitzroy, Victoria 3065,
Australia
e-mail: [email protected]
P. Vafiadis
ISIS Primary Care, 106 Station St., Deer Park, Victoria 3028,
Australia
involvement in pain control decisions, perceiving morphine
as a facilitator rather than a barrier to good cancer care.
Keywords Morphine . Cancer . Perceptions . Attitudes .
General population . Views . Opioids
Introduction
The treatment of cancer pain is multifaceted, encompassing
physical, psychological, social and spiritual elements [1].
Attitudes and personal experiences are important factors in
acceptance and adherence to analgesia, psychological distress
and pain reporting [2]. Morphine has been widely utilised for
the last two centuries as a treatment for cancer pain, in anaesthesia, chronic pain, as an infant soother and for recreational
and habitual use [3, 4] [5]. It has a particularly close association with cancer and end-of-life care [6]. This history and the
unique position of morphine as a medication receiving close
attention in the media and political sphere create a broad array
of patient and public perceptions as to its uses and effects [5, 7,
8]. Such perceptions have a significant impact on the use and
acceptance of morphine in clinical care [9].
The ‘myths of morphine’ have frequently been discussed in
medical literature [7, 10–14]. These have focused on concerns
regarding sedation and cognitive impairment, tolerance, addiction, lack of effect, fear that morphine may signify death is
close and that it may shorten life. It is unclear whether these
myths or understandings are a true reflection of the public’s
perception of morphine or instead reflect the attitudes and
experiences of health professionals. A number of studies have
assessed attitudes to analgesia and morphine in oncology and
palliative care patient populations, allowing a more complex
appreciation of these perceptions to emerge [6, 9, 15].
However, the views expressed in these studies are grounded
in the personal experience of illness and symptoms of patients
Support Care Cancer
and may not reflect a broader community understanding of
morphine use. If the extent of the mythology surrounding
morphine is to be fully comprehended, then the views of a
wider population should be sought.
The aim of this study was to explore the attitudes and
perceptions of a broader community group towards morphine
used in cancer care. These are the people who may in the
future be cancer patients or the family or friends of those who
require morphine. A richer understanding of these attitudes
may lead to improved pain control, improved psychosocial
well-being and a better therapeutic relationship [15].
Methods
This qualitative exploratory study involved interviews with
individuals presenting to a general practice (GP) clinic.
Participants
Participants were adults presenting to an outer metropolitan
GP clinic from April to August 2013. The clinic was situated
in a multicultural and lower socioeconomic urban region of
Victoria, Australia. Eligibility criteria included presenting to a
primary care clinic, being aged 18 or over, being conversant in
English and able to provide written consent. Written consent
was gained at the time of interview. Consecutive sampling
was supplemented by purposeful sampling to ensure diversity
of age and gender.
Data collection
In-depth interviews were conducted by one investigator (MG)
in a general practice clinic. The interviews were semistructured in format, exploring participant’s attitudes and understandings of morphine use in cancer care, beginning with a
narrative account of any experiences of morphine use.
Discussions were focused on the use of morphine, not opioids
in general. Open-ended questions were used, with directive
probes to clarify responses and flexibility to pursue lines of
enquiry consistent with the exploratory nature of the study. A
grounded theory framework was adopted with questions included in later interviews evolving according to the emergent
themes. Interviews were audio-recorded, and field notes were
written consisting of observations and key points. Key areas
covered in the interviews are listed in Table 1.
Theoretical framework and data analysis
Thematic analysis was based on an inductive process that
allowed themes to emerge informed by grounded theory.
The interviews were transcribed verbatim, cross-checked for
authenticity and then thematically analysed by the researchers.
Data was initially analysed by one researcher (MG), then reanalysed in conjunction with the research team (MG, AU, PV
and JP). Data was coded according to keywords, phrases and
subject matter. Concepts were organised by literal and interpretive meanings and grouped thematically into categories.
Themes were collectively discussed, refined and further
discussed between the researchers until agreement was
reached. Analysis was conducted simultaneously with data
collection, with interviews examining these emerging themes
as they became apparent. When no new themes found, saturation was considered to be achieved.
Institutional ethical committee and research governance
permissions were obtained.
Results
Of the 20 people who were approached to participate in the
interview, four declined, and one did not meet eligibility
criteria (due to insufficient English comprehension). Reasons
given for refusal involved insufficient time and unwillingness
to sign consent form. The participants were predominantly
female (73 %), had a mean age of 52 years (range 24–81 years)
and were culturally diverse. Nine of the participants had
themselves previously been prescribed morphine (all use
was for acute or post-operative pain), and eight had involvement with a friend or relative with cancer, with one participant
having a history of cancer though had not used morphine. Use
of morphine was defined as morphine prescribed for outpatient use or administered in an acute hospital setting, with no
participants reporting personal non-medical use. All the participants recognised morphine and had knowledge of its properties as an analgesic. Participants’ characteristics are shown
in Table 2.
Table 1 Overview of key interview points
Previous personal exposure to morphine
Understandings of morphine use
Attitude to morphine use in cancer care
Attitude and understanding of cancer
Understanding of morphine prescribing by doctors
Exposure to cancer care
Effects of morphine
Cultural view of morphine and cancer
Religious perception of morphine and cancer
Expectations of health professional communication prescribing morphine
Support Care Cancer
Table 2 Participant
characteristics
Table 3 Perceptions of cancer
Age
18–40 years
40–60 years
60+years
Cultural background
None identified
Mediterranean
Middle Eastern
Anglo-Saxon
Religion
None identified
Catholic
Islam
Orthodox Christian
4
5
6
7
4
3
1
7
6
1
1
Themes
The use of morphine in cancer care was widely supported by
the participants. Overall, they described a pragmatic attitude to
the use of morphine, balancing the risks of adverse effects
against the benefits. The perception of cancer was central to
this understanding, with cancer pain viewed as severe and
unrelenting, and thus, concern regarding the adverse effects of
morphine was minimal in these circumstances. Participants
detailed the importance of the health professional role in
providing morphine in cancer care, mitigating the risk of
adverse effects. The participants’ views centred around four
main themes: perceptions of cancer, the understanding of
morphine, the impact of morphine on cancer and the role of
the health professional.
Perceptions of cancer
Participants viewed cancer as a disease that was terrible due to
not only a heavy symptom burden but also the way in which
its treatment takes control over the lives of patients (Table 3).
Cancer viewed as inherently painful
Cancer necessitated morphine due to the brutal and unrelenting nature of the accompanying pain. While pain was not
viewed as being present during all phases in cancer, it was
seen as inevitable at some stage in the disease, especially in
the terminal phase. Chemotherapy was viewed as the other
period of cancer treatment when pain was often present.
Participants likened the pain to that sustained from highspeed car accidents and war injuries. Yet, cancer pain was
considered even more horrific, due to its slow and inescapable
nature.
Cancer is viewed as inherently painful
“He was getting himself into that state whether to jump out the window,
you know—that was the better cure… It must be such a type of pain
that it’s horrendous”
“I know that if—if all else fails I know that cancer can be very, very
painful, specifically if you’re waiting to die”
Perceived loss of control
“Look, I am at my end of my life and I do not wish to be survived on a
ventilator or whatever, you know,” and there’s nothing for that person
at the end and if they want the morphine, give it to them”
“I mean I’ve got to be in really a lot of pain before I take anything, but
that’s just me. I mean I know a lot of people, as soon as they’re in pain
they just pop pills or whatever, but I’m not—you know, so I’m not
into stuff like that. But yeah, if it’s really really necessary I’d take it”
This was exemplified by one participant, who had worked
as a medic in wartime and administered morphine to dying
soldiers. He reflected on those experiences, contrasting them
to witnessing two family members die from oncological disease. He described the death from cancer as far worse, since he
was able to provide comfort to a dying pilot with morphine
and kind words, while the gradual decline and constant pain of
his family members rendered him feeling helpless.
Perceived loss of control
Cancer was viewed as a disease that robs the individual of
control over their life, as the future becomes increasingly
medicalised, mandated by a strict treatment regime: with
continual appointments, pathology and imaging tests, chemotherapy and radiotherapy. Participants described the perceived
inevitabilities of sickness, emotional strain and functional
loss. Pain was seen as a further inevitability. The participants
reflected that since cancer took control away from the patient,
there were very few matters in which that the person might
exert choice. Whilst pain was seen as inevitable, the acceptance of analgesia was perceived as one of the few factors over
which the patient could control.
“If that’s what a person is faced with, then that’s what
the person should be able to decide: ‘OK, I’ve got
nothing to look forward to, no surgery can help me,
nothing, and I’m close to death, I want to just be going
peacefully. Give me the morphine, help me!’”
On exploring this issue, the participants reflected that
exercising decision-making and autonomy was of prime importance in cancer care. The acceptance of morphine for pain
was viewed as highly personal. To accept or refuse the use of
morphine was not a denial or otherwise of pain but often an
individual in a seemingly helpless situation attempting to gain
control over a facet of their life.
Support Care Cancer
Understandings of morphine
All participants recognised morphine and its use in a number
of settings: in cancer care, on the battlefield, in terminal illness
and in the realm of addiction (Table 4).
Powerful morphine
As cancer pain was seen as being severe in nature, the participants viewed morphine as being in a class separate from other
analgesics—as the ‘strongest painkiller’. Those participants
who described their own use of morphine recognised it being
used only in times of ‘severe’ pain when other medications
had been ineffective. The participants detailed the way in
which nursing staff continually monitored patients during
the period of morphine use and then ‘stepped down’ to weaker
analgesics, indicating that it was a drug with powerful effects.
Other experiences relayed were the use of morphine for soldiers who had been terminally injured in war movies, when its
administration turned screams to a sudden peacefulness—
demonstrating the power and immediacy of the medication.
This idea of power was limited not only to the strength of
analgesia but also to its side effects. In particular, the power to
cause addiction was of greater concern with morphine than
other drugs. Other matters such as nausea, euphoria and
drowsiness were also mentioned, though these were less
concerning. A few participants indicated that morphine had
a role in ‘treating the cancer’ similar to chemotherapy, again
contributing to its powerful and almost ‘mystical’
characteristics.
Treatment of last resort
The participants detailed the concept of morphine as a last
resort, but this was not in relation to proximity to death or
disease status. Explicitly, the introduction of morphine was
not perceived as being clearly indicative of terminal disease,
Table 4 Understandings of morphine
Powerful morphine
“I could see his ribs, I could see his heartbeat. It was scary, looking at
my husband in that way, he was chopped up like—but they saved
him. Whatever the consequences were, they saved him. The
morphine did him good”
“Even my husband, he had a heart attack—they didn’t give him
anything like that (morphine)”
“I suppose (morphine is used) to try and kill the bug”
Treatment of last resort
“And I know that it (morphine) is used for mainly cancer patients just
to get rid of the pain that they—that they would have while
undergoing chemotherapy, or…if there’s nothing else to be done for
them”
as the participants believed that it could be used at any time
during cancer treatment as a response to pain, especially
during chemotherapy. Instead, its recognition as the strongest
painkiller meant that it was perceived as being the ultimate
hope for cancer pain treatment. This concept of ‘last resort’
was based on morphine being the final hope for pain relief, as
the participants believed that there were no other perceived
legal alternatives with the same ability to treat cancer pain.
Participants described the time near death as a period where
morphine may be commonly used but did not regard the
initiation of morphine as signifying impending death. They
did however associate the use of morphine with a progression
of disease, believing there was a close relationship between
pain and disease burden.
Impact of morphine on cancer
Participants described the important role of morphine in cancer care, allowing the patient control of pain and lessening the
burden of disease (Table 5).
Achieving peace
A constant theme was the goal of achieving peace. This state
was summarised through a number of phrases: ‘ease the soul’,
‘relax’, ‘provide peace’ and ‘ease the journey’. This state was
not only seen as pre-terminal but could also occur at any time
during the course of cancer treatment, though it was perceived
that prior to death was the time when it may be most sought.
The state in which this peace was most needed was in the last
stages of life when there was little perceived benefit of continued existence. There appeared to be a connection between
the perception of the suffering and pain of cancer, the lack of
Table 5 Impact of morphine on cancer
Achieving peace
“If it’s at that stage where it’s inevitable then it’s going to help them
to—yeah, enjoy the rest of their days, I guess it’s a good thing”
“I think that sometimes it (morphine) is a way of trying to calm the
body, but also letting them know that you know it’s like such a
violent or such a painful passing. So—‘cos no-one knows really what
it’s like to go into that field where you’re crossing over to your end of
life”
Effect on life expectancy
“I believe hospitals generally use it to help the patient along sort of
when it’s getting closer to the end for them to just relieve it. And I
believe that they up the dose as it goes on for them to speed things up
and help them towards the end”
“I go to the experience that I’ve had with my family who’ve been on
morphine. To tell you the truth, it prolonged the life, well it’s made
their life a little bit more comfortable”
Support Care Cancer
control and the requirement for a state of tranquillity. A state
of peace was perceived as vital to good cancer care and a good
death.
Morphine was believed to assist in achieving such a state of
peace. There was uncertainty as to exactly how it might assist
but would, in a general way, ease anxiety and distress. One
participant described his father who had died of brain cancer
and his agitated and aggressive confusion in the last months of
his life that settled when given an injection of morphine:
“He get (sic) like crazy, you know what I mean…takes
clothes off and walk around the corridor… He doesn’t
know what is going on, but if he doesn’t get morphine,
he starts more trouble.”
Table 6 The role of the health professional
Trust in health professionals
“She was scared of getting addicted but then the palliative nurse come
out and explained to her, look you know you’re not going to get
addicted to it (morphine). So she thought OK we’ll try it. She’s tried it
so now, when she has got the pain or shortness of breath she asks one
of us to give (it to) her”
“You’ve got to treat it properly or you—you can either kill yourself if
you don’t treat it properly, you can become addicted to it, other
different things…I just have it as the doctors give it to me and then
after that, that’s it”
The importance of communication
“Instead of just saying: “Oh, we’re going to use it for pain,” you know,
be honest. That’s all people really these days are wanting, well
myself. I would rather someone be honest with me”
“I would hope that it was never used to try and say to a person—don’t
worry, everything’s all right, it’s not all right, because it’s better to tell
them what is going on”
Effect on life expectancy
Views on morphine influencing life expectancy were widely
varied. The majority of participants believed that it had no
effect on survival; some perceived that it was used by doctors
to assist in shortening the terminal phase, whilst others believed that it might extend life.
The perceived effect of morphine on life expectancy produced strong responses from the participants. They described
the central goal of care was to achieve peace and freedom
from pain, rather than focusing on life expectancy. Those
participants who perceived that morphine may shorten the life
expectancy in cancer care as a secondary effect were supportive of its use. All participants stated that prolongation of the
terminal stage was against the ideal of peace and to minimise
the length of process of dying (or not prolong it) was concordant with minimal suffering.
The role of health professional
The role of the health professional in administering morphine
appropriately was viewed as being vital to protecting patients
from harm and curbing wider societal problems such as addiction (Table 6).
Trust in health professions
Participants believed that due to the strength and adverse
effects of morphine, there was a compelling requirement for
controlled, responsible prescribing and provision by health
professionals. They were confident that the current medical
system upheld these values, describing trust in the manner in
which doctors prescribed, serving the best interests of the
patient. Concerns regarding morphine side effects such as
nausea, euphoria and constipation were minimised due to
the close supervision by health professionals.
The importance of communication
Communication at the time of prescribing morphine was
identified as an important issue for participants. They wanted
to know why they might require morphine, for what duration,
its long-term effects and what relevance it had to the stage of
cancer treatment. They believed that any risks should be
acknowledged and discussed, as participants recognised that
there are possible complications and wanted to be aware in
advance.
Although all participants agreed on the importance of
communication, those who had experienced morphine use
(either as patient or through family and friends) described a
general lack of communication and information presented by
the doctor. The participants reported that their experiences
often lacked detail correlating the patient’s understanding of
their illness with the use of morphine. A number of individuals
remarked upon the phrase ‘to treat pain’ used by doctors,
feeling that this was ambiguous in nature and could encompass a number of various purposes. Was morphine being used
only to treat pain, to provide peace or to treat the cancer?
Those participants with experience of terminal cancer care
voiced some concern that the purpose was not communicated
to their loved one and family, leading to further insecurity in
what was already a tumultuous time.
Discussion
To our knowledge, this is the first study to examine the
attitudes and understandings of morphine in cancer care in
Support Care Cancer
the general population. While the beliefs and attitudes of this
population have much in common with those with cancer or
chronic disease, a number of different themes and emphases
have emerged.
Previous quantitative studies examining attitudes to analgesia in patient populations have focused on concerns regarding addiction, tolerance, side effects, the importance of communication and the notion of the last resort [16–19].
Qualitative studies of oncological and chronic disease populations examining this issue have unearthed a range of attitudes, allowing a greater understanding of the perceptions and
use of opioids. Concerns regarding opioids were a significant
factor in these studies, yet other issues such as communication, past experiences of use and trust in health professionals
were also deemed of great importance [6, 9, 20]. The individual’s personal story of cancer and ideals of suffering and
control over the illness were important factors in their perception of analgesia use [5]. The understanding and attitudes
towards cancer and opioids are diverse and often complex
and, without due attention, can lead to poor clinical outcomes
and heightened patient and family anxiety [7].
The perceptions presented by patient populations share
similarities with this study yet strongly focus on the risks
and negative connotations associated with analgesia use (i.e.
addiction, tolerance) rather than the more pragmatic approach
presented by the participants in this study [6, 7]. Notions such
as morphine as a last resort were starkly different, as patient’s
viewed its use as associated with impending death, yet in this
study, it was described as the strongest (and thus last used)
analgesic. It is a different understanding to that presented by
patients, whose perceptions are influenced by their personal
journey of pain and illness, their attitudes often reflecting
current health issues and existential concerns [21].
The mythology of morphine
This study has shown that in this sample, the myths of morphine presented in the medical literature are not concordant
with the perception of the general public. Notions such as
association with end-of-life care, tolerance, side effects other
than addiction and life-limiting properties were of limited
concern to the participants in this study, yet they have been
discussed through literature as long-standing barriers to analgesia provision [7, 11, 15, 19, 22].
The area of greatest interest to the participants was the
intended use of morphine, and how it related to the patient’s
illness. They perceived morphine was used by doctors for a
number of reasons: as an analgesic, a provider of peace or a
treatment for cancer. The ‘myths’ have not detailed this concept, despite it being discussed by many of the participants in
an array of forms. Those who had experience of morphine use
in cancer care described this as a time of limited information
and ambiguous communication. They place great trust and
importance in the relationship with health professionals, as
has been evident in other studies, yet further work is required
to align understandings of use and communicate this effectively [6].
The mythology of morphine has generally been understood
as perceptions of both health professionals and patients [7,
11]. Many of these myths are viewed as barriers to proper
health care provision, especially concerns around side effects
and association with death [17]. It appears that these barriers
around morphine may find their basis in the perception of the
health professional to a greater extent than we might realise
[13, 23]. The attitudes of the participants towards morphine
used in cancer care were overwhelmingly positive and
reflected an area of health care which individuals wanted to
understand and be engaged with. They voiced willingness for
greater involvement in their analgesia choices, wishing to
understand options for treatment and how pain correlates with
their ideal of good health and a good death. The myths or
‘barriers’ to analgesia use may instead be a reflection of health
professional concerns, especially at times when information
and communication needs of patients and family are not
addressed.
Limitations
This is a single-centre study set in an outer metropolitan
general practice clinic in a relatively low socioeconomic area
of Melbourne, Australia, and therefore, the findings may not
be generalised to all groups. That said, there was diversity of
age, ethnicity, religion and experiences with morphine and
cancer care within the population interviewed. Participants
were predominantly female; however, the gender of those
individuals who registered interest in the study was similar
to that presented to Australian general practice [24]. It is
understood that qualitative studies aim to explore the range
of possible views and that determination of representativeness
of the views would require a quantitative approach.
Conclusion
The understanding of morphine is complex, built on an array
of experiences through medical care, exposure in film and
media and influenced by historical beliefs. These attitudes
have the ability to influence pain and its management, psychological distress, and family and health professional relationships, especially at the end of life [15, 17].
The myths of morphine have long persisted in the medical
literature yet possibly reflect an understanding based on health
professionals’ experiences of care, rather than true societal
beliefs around morphine [10, 11]. The participants in this
study wished to be involved in their analgesia choices and
Support Care Cancer
perceived morphine as an important and highly useful component of cancer pain treatment. Terminology surrounding the
use of morphine has focused on apprehension, barriers and
fear, yet the views of the participants in this study do not
support such positions [7]. Perhaps, we as health professionals
need to move beyond our perception of morphine as a barrier
and, instead, view it as an opportunity to engage patients,
family and friends in discussions regarding treatment and
analgesia options [25]. Involving the patient in communication regarding morphine is central to reducing ambiguity
around indications and to providing greater autonomy within
the experience of illness.
Conflict of interest Matthew Grant was previously employed as a
pharmacovigilance physician by MSD; however, he has no ongoing
relationship with the company.
References
1. Clark D (1999) ‘Total pain’, disciplinary power and the body in the
work of Cicely Saunders, 1958-1967. Soc Sci Med 49(6):727–736
2. Potter VT, Wiseman CE, Dunn SM, Boyle FM (2003) Patient barriers
to optimal cancer pain control. Psychooncology 12(2):153–160
3. Manderson DRA (1988) The first loss of freedom: early opium laws
in Australia. Aust Drug Alcohol Rev 7(4):439–453
4. Grant M, Philip J, Ugalde A (2014) A functional dependence? A
social history of the medical use of morphine in Australia. Med J Aust
200(4):230–232
5. Flemming K (2010) The use of morphine to treat cancer-related pain:
a synthesis of quantitative and qualitative research. J Pain Symptom
Manag 39(1):139–154
6. Reid CM, Gooberman-Hill R, Hanks GW (2008) Opioid analgesics
for cancer pain: symptom control for the living or comfort for the
dying? A qualitative study to investigate the factors influencing the
decision to accept morphine for pain caused by cancer. Ann Oncol
19(1):44–48
7. Maltoni M (2008) Opioids, pain, and fear. Ann Oncol 19(1):5–7
8. Shoemaker PJ (1989) Communication campaigns about drugs: government, media, and the public: L. Erlbaum Associates, Hillsdale, NJ
9. Oxberry SG, Jones L, Clark AL, Johnson MJ (2012) Attitudes to
morphine in chronic heart failure patients. Postgrad Med J 88(1043):
515–521
10. Zenz M (1991) Morphine myths: sedation, tolerance, addiction.
Postgrad Med J 67:S100
11. Forbes K (2006) Opioids: beliefs and myths. J Pain Palliat Care
Pharmacother 20(3):33–35
12. Doyle D (1991) Morphine: myths, morality and economics. Postgrad
Med J 67(Suppl 2):S70–S73
13. Elliott TE, Elliott BA (1992) Physician attitudes and beliefs about use
of morphine for cancer pain. J Pain Symptom Manag 7(3):141–148
14. Lossignol DA (1993) Pitfalls in the use of opiates in treatment of
cancer pain. Support Care Cancer 1(5):256–258
15. Ersek M, Miller Kraybill B, Du Pen A (1999) Factors hindering
patients’ use of medications for cancer pain. Cancer Pract 7(5):226–
232
16. Bennett MI, Graham J, Schmidt-Hansen M, Prettyjohns M, Arnold S
(2012) Prescribing strong opioids for pain in adult palliative care:
summary of NICE guidance. BMJ Br Med J 344:42
17. Ward SE, Goldberg N, Miller-McCauley V, Mueller C, Nolan A,
Pawlik-Plank D et al (1993) Patient-related barriers to management
of cancer pain. Pain 52(3):319–324
18. Gunnarsdottir S, Donovan HS, Serlin RC, Voge C, Ward S (2002)
Patient-related barriers to pain management: the barriers questionnaire II (BQ-II). Pain 99(3):385–396
19. Paice JA, Toy C, Shott S (1998) Barriers to cancer pain relief: fear of
tolerance and addiction. J Pain Symptom Manag 16(1):1–9
20. Seymour JE, Bellamy G, Gott M, Ahmedzai SH, Clark D (2002)
Good deaths, bad deaths: older people’s assessments of the risks and
benefits of morphine and terminal sedation in end-of-life care. Health
Risk Soc 4(3):287–303
21. Halldórsdóttir S, Hamrin E (1996) Experiencing existential changes:
the lived experience of having cancer. Cancer Nurs 19(1):29–36
22. Zenz M, Sorge J (1991) Is the therapeutic use of opioids adversely
affected by prejudice and law? In: Senn H-J, Glaus A (eds).
Supportive care in cancer patients II. Recent results in cancer research. 121. Springer, Heidelberg, pp 43–50
23. Momen N, Hadfield P, Harrison K, Barclay S (2012) Managing pain
in advanced cancer: a survey of United Kingdom general practitioners and community nurses. J Pain Symptom Manage 46(3):
345–54
24. Britt H, Miller GC, Charles J, Henderson J, Bayram C, Pan Y, et al
(2009) General practice activity in Australia 2008-09: Australian
Institute of Health and Welfare, and University of Sydney
25. Vafiadis P (2001) Mutual care in palliative medicine: a story of
doctors and patients. Roseville, N.S.W. McGraw-Hill, Australia