Why Pain Relief at the End of Life Matters
For people living with advanced cancer, pain is one of the most common and distressing symptoms. Up to 90% of patients experience pain as they near the end of life. Effective treatment matters not just for comfort, but for dignity, quality of life, and even survival. Opioids like morphine, when used appropriately, can control pain for the vast majority of patients. International guidelines — and the Lancet Commission on Pain Relief — are clear: access to pain relief is a human right. Yet despite this, not everyone receives the pain relief they need. In this blog, we will explain what we did, what we found and why our findings matter.
What We Set Out to Explore
Previous studies from the United States have shown stark racial and ethnic inequalities in opioid prescribing for people with cancer. Minority ethnic patients were less likely to receive pain medication, even when other factors like age, insurance, or cancer type were considered.
But until now, we didn’t know whether these same inequities existed in the UK’s NHS. That was the driving question behind our new study: are there ethnic disparities in opioid prescribing for cancer pain at the end of life in England? And if so, what does this mean for patients and health services?
Our study just published in the British Journal of Cancer (Chukwusa, E., Law-Clucas, S., Gulliford, M. et al. Ethnic disparities in opioid prescribing for cancer pain and associated emergency department visits and hospital admissions in the last three months of life: a retrospective cohort study. Br J Cancer (2025). https://doi.org/10.1038/s41416-025-03200-4) examines this issue in detail. We analysed anonymised primary care records from the Clinical Practice Datalink for more than 232,000 adults with cancer from all ethnicities who died between 2011 and 2021. These records were linked to hospital and mortality data, creating one of the largest population-based studies of its kind in England.
We focused on the final three months of life — the period when cancer pain is most common and often most severe. We looked at:
- Opioid prescriptions issued in the community,
- Emergency department visits, and
- Hospital admissions.
We adjusted our analyses for important demographic and clinical factors such as age, sex, cancer type, deprivation, comorbidities, region, and whether patients were registered for palliative care.
What We Found
The results are sobering.
- Patients from minority ethnic backgrounds were prescribed fewer opioids than White patients in their last months of life.
- The quantity of opioids prescribed was also lower. When measured in morphine milligram equivalents, patients from minority ethnic backgrounds received smaller doses of medicine overall.
- Healthcare use told another part of the story. Patients from Black, South Asian, and Mixed ethnic groups were more likely to have multiple emergency department visits and hospital admissions in their final months. This suggests that inadequate pain relief in the community may be pushing people into acute care.
Why Does This Happen?
Our study cannot tell us exactly why these disparities exist — but research and lived experience point to several possible explanations:
- Cultural and personal beliefs about opioids. Some patients may fear dependency or worry that pain medicines will hasten death.
- Communication barriers. Language differences and difficulties in expressing pain can hinder care.
- Mistrust of health services. The COVID-19 pandemic made visible longstanding inequalities that fuel mistrust.
- Clinician bias. Evidence from the US shows doctors may be more reluctant to prescribe opioids to minority ethnic patients due to fears of misuse — a concern not justified in the context of cancer pain.
- System-level issues. Policies shaped by concerns about opioid misuse in non-cancer settings may inadvertently worsen inequities.
The truth is likely to be a combination of all these factors.
Why It Matters
Pain control at the end of life is not optional — it is a cornerstone of compassionate, high-quality care. To know that some groups of patients consistently receive less pain relief is both ethically indefensible and deeply concerning for health equity.
These findings highlight that the NHS, despite its universal principles, is not immune to structural inequities. Without action, we risk compounding suffering for people already facing disadvantage.
What Needs to Change
Addressing this issue requires urgent attention across policy, practice, and research:
- Awareness and education. Clinicians need training to recognise and challenge unconscious bias, communicate effectively across cultures, and engage with patients’ values and concerns.
- Better data. Health services must routinely monitor prescribing patterns by ethnicity to identify where disparities occur.
- Community engagement.