• Pain
• Psychological care

We read with interest the article by Sharon et al 1 about the use of medical cannabis in ‘cancer-related pain management in advanced stages’.

Dame Cicely Saunders coined the concept ‘total pain’. She observed the multidimensional nature of suffering of patients with cancer in palliative care, which included physical, psychological, social and spiritual dimensions.2 Saunders taught that patients may describe their psycho-spiritual-social suffering as physical pain. We see this with the expression, ‘I have pain all over’.

‘The concept of ‘total pain’ should be the driving force leading to the standardization of pain definition, intervention, and evaluation for patients with cancer in palliative care’.3 Today, many decades later, the psychosocial aspects of pain are well recognised in all fields of pain research and management.

At our pain and palliative care clinic, many patients pursue medical cannabis treatment, seeking a ‘natural’, non-opioid remedy to relieve pain and to cure their cancer.4 However, for the great majority of patients with complex severe cancer pain, medical cannabis fails to live up to its hype. Nevertheless, many of them will continue using cannabis along with opioids and adjuvants.

We suspect the reason is that cannabis is used as a form of chemical coping to relieve the anxiety, which accompanies the physical pain.5 We argue that the improved pain scores while using cannabis may be due to relief of psychological distress. The pain scores are serving as an indirect marker of Saunders’ ‘total pain’.

Hence, we think it is imperative that studies such as these by Sharon et al 1 in cancer palliative care include measures of psycho-spiritual-social distress.

Dame Cicely Saunders taught us many years ago that patients experience ‘total pain’ and not just ‘refractory cancer-related pain’. It is as relevant today as back then.