SAVES is not affiliated with Exit International / Dr Philip Nitschke and opposes the public availability of a 'peaceful pill'.

SAVES members welcomed Dr Bruce Rounsefell who spoke on the topic Successes and limitations of current pain management techniques. He explained that there are three types of pain: acute, chronic, and the pain associated with cancer. Acute pain, while distressing, plays a valuable role as a warning sign, but the function or value of chronic pain is hard to establish. Cancer pain is a mixture of both, as disease involves a series of acute pains. Dr Rounsefell stated that it is not possible to give satisfactory treatment in all cases and research continues for even better techniques. There are widespread changes in the body due to pain, including cardiovascular, respiratory, muscular and even hormonal.

Secondary pain is ubiquitous, as the brain and the body are not separate entities and there are emotional responses of fear and anxiety. Depression and anger are normal emotional responses to chronic pain, and clinical depression may need to be managed. Dr Rounsefell claimed that ninety percent of patients with cancer get relief from oral analgesia, seven percent get good relief with other forms of pain relief delivery, while three percent have spinal catheters inserted which require only one percent of the equivalent oral medication.

Pain is life changing, and severe pain stressful to the extent that it can be considered a chronic illness in itself. The efficient delivery of pain management may extend the life span. However there are limitations and barriers to good pain relief. The side effect of drugs is one, as there is no such thing as a drug without side effects, even though some are of very high quality. Complex pain also requires a range of medications.

Another limitation is that neuropathic pain is often not relieved by morphine and there are difficulties in drug delivery. For instance some patients cannot swallow and will need infusions or injections. Sometimes there is a failure to address other issues, including the emotional and spiritual dimensions of pain and dying. Emotional distress makes pain relief difficult and palliative care may play an important role. Dr Rounsefell claimed that humour can play a crucial role in managing pain, and that some people gain benefit from humour, even within the framework of very distressing circumstances.

A particularly difficult and upsetting limitation to successful pain relief is the unexpected lack of response to medication. Some pain is so intractable that it may be necessary to immobilise, or induce paraplegia to alleviate it. TENS machines deliver an electric impulse to peripheral nerves to 'scramble' pain messages, and promote the production of endorphins. However they have variable success as the body may try to adapt to the machine, thereby making it less effective.

Both heroin and morphine have the same pain relief properties but differ in their euphoric effect, with heroin being particularly addictive due to this property. There are also different receptors for pain relief and euphoria. Dr Rounsefell reminded the audience how societal attitudes have changed, with the result that there is now a greater stigma attached to heroin use.

The use of steroids such as cortisone, which have anti-inflammatory properties reveal a success rate of approximately fifty per cent. He also advised that as people age it becomes more difficult to get the appropriate level of medication, with methadone being particularly problematic. However the rotation of opiates is one way to avoid a growing tolerance to any one medication. Changing to an alternative opiate will often allow effective pain relief from a lower dose.

These medical barriers to effective pain relief are exacerbated by 'horrendous' waiting lists at every pain clinic. Cancer patients are given greatest priority, with a four to five month wait for other conditions. Those people already seen by the clinic, but needing further treatment, may wait twelve months. The waiting list for multi-disciplinary team assessment is between six and ten months. There is very limited training for university students, while long waiting lists may discourage doctors from even referring patients to clinics.

The topic inspired many questions from the floor and provided much needed information for members. It is understandable that Dr Rounsefell chose not to comment on the issue of voluntary euthanasia. However one of the more interesting questions posed was whether or not it was feasible that merely knowing that voluntary euthanasia was available as a final option, may itself offer some relief of pain and anxiety. Dr Rounsefell considered that it was quite possible, as pain is highly complex, being both emotional and physical.

This important discussion reinforced the need for us to acknowledge the many pain management successes in recent years. However it also revealed serious limitations and challenges both at the clinical and resource level. This is despite the constant claims by opponents of voluntary euthanasia that sophisticated pain management has all the answers, and politicians stating repeatedly that they support greater pain management and palliative care services.

Unless there is a large injection of funds for pain management, these huge challenges will continue for both practitioners and patients suffering from a range of distressing and painful conditions. Even then there will always be a small minority of patients whose suffering will only ever be able to be relieved by voluntary euthanasia.

Arguably the debate on voluntary euthanasia will continue to raise public awareness and thereby play an important role in advocating for improved pain management techniques and reduced waiting lists at pain clinics, while as a law reform society, we continue to promote choice for voluntary euthanasia.

Julia Anaf