The World Health Organization analgesic ladder for cancer pain relief is an internationally used approach to managing cancer pain. Patients generally start on Step 1 of the ladder (paracetamol). As pain increases or is not well controlled on this, they progress to Step 2 which involves a stronger pain killer (weak opioid such as codeine). If pain is still not controlled they progress to Step 3 of the ladder which is a strong opioid (such as morphine). Work to date has suggested that Step 2 may be unnecessary and most patients usually require Step 3 analgesia. The TVT trial aims to examine the standard approach (Step 1-Step2-Step-3) versus a two step approach (Step 1-Step 3).

Inclusion Criteria:

• 18 years of age and over.
• Patient has a cancer diagnosis (based on radiological, histological, cytological, or operative evidence). Those with haematological malignancies are eligible.
• Cancer related pain - which in the opinion of the clinician is caused by the presence of tumour or metastases.
• Average pain score > 4, on a numerical rating scale from 0-10, requiring step 2 analgesia (weak opioid).
• Patient is able to comply with trial procedures.

Exclusion Criteria:

• Patients who have received radiotherapy in the previous 6 weeks or are planned to receive radiotherapy during the trial period where in either case, it is expected to affect pain during the trial period.
• Pain due to surgery in the preceding 4 weeks.
• Life expectancy less than two months (based on clinical impression).
• Patients with psychotic disorders or cognitive impairment.
• Patients who have received regular doses (scheduled doses - NOT as required dosing) of weak or strong opioids in the preceding two weeks.
• Patients using immediate release opioids > 2 doses/24 hours, in the previous 24 hours.