The following are some reasons for un relieved pain:

!. Related to patient

Failure to report pain.  Belief that pain is inevitable. Belief that pain is untreatable. Putting on a brave face, not wanting  to trouble the doctor.

Failure to take medication (non-compliance). Side effects. Physically cannot take the medication. Does not believe in medications. Fear of tolerance, dependence, having nothing in reserve for more severe pain.

2. Related to treatment team

Disbelieve the patient.

Inaccurate assessment of the type and cause of pain.

Poor choice of treatment modality, failure to use multiple modalities

Poor use of analgesics. Wrong strength or type of analgesic. Wrong dosage. Lack of provision for breakthrough pain. Failure to warn, or give treatment to prevent side effects. Failure to use adjuvant analgesics. Withhold opioid analgesics for terminal care or for fear of tolerance and dependence.

Failure to both relieve chronic pain and prevent its recurrence.

Failure to communicate with and involve the patient in treatment

Failure to provide continuity of care.

Failure to assess and treat other aspects of suffering (physical, psychological, social, cultural, spiritual) that may cause or aggravate pain.

Failure to reassess.

All are preventable or treatable. Some are inexcusable. The assessment of unrelieved pain requires a check list based on the principles of treatment. In most cases, the cause is obvious.

Even with optimal treatment of pain and the best of multidisciplinary palliative care, the management of unrelieved pain remains extremely difficult. Some of these patients have unresolved psychological, social, or spiritual problems. The treatment team has to do its best to minimise suffering and keep trying to resolve the underlying issues.

Very few patients with pain that cannot be relieved by the optimal therapy now available. Optimal therapy involves the use of drugs together with appropriate attention to psychosocial and spiritual matters. The treatment of cancer pain continue to improve. Advances in the twenty years include the use of continuous subcutaneous infusions of morphine, spinal opioid therapy, and the introduction of sustained release oral morphine.