The incidence of oncological diseases and mortality due to them remain a leading clinical and social problem at the national and global levels and show a tendency to increase. According to the World Health Organization (WHO), cancer can claim more than 13 million lives [1, P.169]. Pain syndrome is the most common and non-specific manifestation of diseases caused by malignant neoplasms and accounts for almost two-thirds of all cases of a generalized process; 30–40% of patients suffer from moderate or severe pain, which is chronic in nature; 40–55% experience pain at the stage of generalization, during and after antitumor therapy, and in the terminal stage of the tumor process [2, P.1].
A new type of medical care is actively developing and being introduced into practical medicine—palliative medicine, or palliative care—which involves the use of various methods of pain relief in patients with oncological diseases [3, P.318]. The need for pain relief arises at different stages of the disease and stages of its treatment, from the initial consultation with a family doctor to specialized examination and treatment by an oncologist, chemotherapist, or radiotherapist. The primary task is to determine the nature of pain (nociceptive, neuropathic, psychogenic, or mixed), its intensity, and to identify the cause and pathogenesis of the pain syndrome [5, P.18]. For this purpose, the “Plan of observation of a patient in need of palliative care” was used and analyzed. It contains a large amount of subjective and physical information obtained directly from the patient and recorded by completing the relevant sections. Section 6 of this plan includes various characteristics of pain (nature, localization, extent, intensity, and previous use of analgesics).
Most often, chronic pain syndrome develops due to secondary metastases to bone tissue located in close proximity to the primary tumor site. Breast cancer metastasizes to the thoracic spine and ribs in 70–80% of cases, with corresponding pain localization; in lung cancer, pain and metastases are diagnosed in the thoracic or lumbar spine in 55–60% of cases; in kidney cancer, cancers of the pelvic organs in women, and prostate cancer, pain and metastases to the pelvic bones and lumbar spine are observed in 50–55% of cases [4, P.3].
There are general approaches that ensure similar principles of palliative care in accordance with international standards, as well as specific features of state regulation in different countries. These features are demonstrated by comparing pain relief practices in Ukraine and Morocco.
States have formal policies and clinical guidelines for palliative care, enshrined in the National Cancer Prevention and Control Plan and the National Palliative Care Guide (2018–2022). Services are gradually being integrated into cancer care networks, with increasing but still uneven coverage across regions. Service provision is concentrated in regional cancer centers, which reduces social and logistical barriers to care. The legal framework for narcotic and psychotropic drugs, which are essential for end-of-life pain management, is based on the implementation of professional regulations, including strict restrictions on prescribing, dispensing, and record-keeping obligations. The burden of cancer and other life-limiting conditions has led to the inclusion of palliative care as a key component of the national response to cancer, with defined actions to expand symptom control, psychosocial support, and continuity of care in hospital, outpatient, and home settings. The national guideline identifies the required interdisciplinary team (physicians, nurses, pharmacists, psychologists, social workers, spiritual workers, and volunteers) and establishes expected competencies for pain assessment, opioid therapy management, and end-of-life communication.
The legal framework regulates the production, importation, storage, prescription, dispensing, and use of narcotic drugs, as well as related offenses. It establishes penalties for violations and provides compliance mechanisms, forming the basis for the availability of opioids for palliative pain control. Moroccan professional and ministerial guidelines on narcotic and psychotropic substances define specific prescription requirements and registries for controlled drugs, as well as limits on prescription duration and quantity. In particular, it is prohibited to prescribe or dispense narcotic drugs for a period exceeding seven days. Prescription records must be kept for ten years and presented upon inspection. These regulations are crucial for palliative practice, as they determine how hospitals and community pharmacies store, prescribe, and dispense morphine, fentanyl, buprenorphine, and other opioid analgesics, and how continuity of care at home is ensured at the end of life.
Ensuring and implementing these principles is impossible without a personalized approach to the selection and continuation of palliative pain management. This requires structured palliative assessment, including the use of validated pain scales at each patient encounter, adherence to national clinical algorithms for symptom control and transition to home care, and active planning for the continuity of opioid therapy, including coordination between hospitals and community pharmacies. Pain management usually includes continuous 24-hour analgesia to maintain a stable opioid concentration, means for the relief of breakthrough pain, and changes in the route of drug administration as the disease progresses, with preference given to sublingual, transdermal, or parenteral routes. International standards recommend a stepwise analgesic approach, progressing from non-opioid analgesics to weak opioids and then to strong opioids; however, in cases of severe cancer pain, clinicians often initiate therapy with strong opioids, titrating the dose according to clinical effect and adding adjuvant medications (e.g., dexamethasone for edema, gabapentinoids for neuropathic components).
A general conclusion can be drawn: the treatment of acute and chronic pain in cancer patients in Ukraine and Morocco is regulated by relevant standards that ensure adherence to a consistent three-step approach. This includes the use of non-steroidal anti-inflammatory drugs and non-narcotic analgesics for mild pain, weak opioids for moderate pain, and strong opioids for severe pain. Escalation or de-escalation regimens are applied individually, depending on pain severity and drug-related risks. A significant number of oncological diseases accompanied by chronic pain require palliative treatment in specialized departments.
Literature
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2. Rolf A H Snijders , Linda Brom , Maurice Theunissen, Marieke H J van den Beuken-van Everdingen Update on Prevalence of Pain in Patients with Cancer 2022: A Systematic Literature Review and Meta-Analysis // Cancers (Basel). - 2023 Jan 18;15(3):591.
3. Margaux Evenepoel, Vincent Haenen, Tom De Baerdemaecker, Mira Meeus, Nele Devoogdt, Lore Dams, Sophie Van Dijck, Elien Van der Gucht, An De Groef Pain Prevalence During Cancer Treatment: A Systematic Review and Meta-Analysis // J Pain Symptom Manage. - 2022 Mar;63(3):e317-e335.
4. Li B.T., Wong M.H., Pavlakis N. Treatment and Prevention of Bone Metastases from Breast Cancer: A Comprehensive Review of Evidence for Clinical Practice. J Clin Med. 2014;3(1):1–24.
5. Helen Wood , Andrew Dickman, Angela Star and Jason W Boland Updates in palliative care – overview and recent advancements in the pharmacological management of cancer pain // Clinical Medicine 2018 Vol. 18, No 1: 17–22.
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