A comprehensive review of pain management may be found in Chapter 33.

Palliative Care Considerations

• According to the SUPPORT study, 74% to 95% of very ill or dying patients still experience uncontrolled pain. Although existing drug therapy affords the opportunity to manage over 90% of pain, many patients needlessly suffer.40

• As with any pain management, patient assessment is key to choosing appropriate therapeutic interventions. Because pain is subjective, both physical and humanistic factors must be considered.

• Patients in an end-of-life setting must also be evaluated for anxiety, depression, delirium, and other neurologic influences that may heighten a patient's awareness or response to pain.

Nonpharmacologic Treatment in Palliative Care

• Nonpharmacologic treatment is essential in chronic pain management.

• Physical, complementary, and cognitive behavioral interventions reduce the perception of pain and decrease the dose requirements of medications. Examples of such strategies may include education and information about medical treatments (e.g., misconceptions about pain medications), massage, ice, heat, physical therapy, music therapy, imagery, pet therapy, psychotherapy, etc.

Pharmacotherapy in Palliative Care

• The WHO's approach to pain management is still appropriate for most nociceptive pain (see Chap. 33).

• Pain should be assessed thoroughly and frequently, especially at the onset of treatment.

• For chronic, constant pain, around the clock dosing of analgesics are usually neces-



• When titrating opioid doses, increase daily maintenance doses by 25% to 50% if patients are requiring two to three breakthrough doses per 24 hours. The dose of opioids for the treatment of breakthrough pain should be equal to 5% to 15% of the daily maintenance dose. Frequencies for breakthrough dosing should not exceed the following:

• Subcutaneous: every 20 to 30 minutes

• Intravenous: every 6 to 20 minutes

• Only short acting opioids should be used for breakthrough pain (e.g., immediate-release morphine, oxycodone, and hydromorphone are common examples).

• Monitor for and appropriately treat common side effects of opioids. Common side effects of opioids include constipation, nausea and vomiting, itching, and transient sedation.

• Because constipation occurs with all chronic opioid therapy, prevention is imperative. Stimulant laxatives (senna or bisacodyl) with or without a stool softener (docusate) are the drugs of choice for opioid-induced constipation.

• Myoclonus, delirium, hallucinations, and hyperalgesia are possible signs of opioid neurotoxicity and require a change in opioid therapy or dose reduction.

• Respiratory depression is very uncommon with appropriate opioid dose titration. However, if it does occur, small doses (0.1 mg) of the mu receptor antagonist, naloxone, are appropriate and can be repeated if necessary. The goal is to increase respirations to a safe level while preventing the patient from experiencing a loss of pain control.

• Fentanyl transdermal patches may be appropriate in some patients however many end-of-life patients experience muscle wasting and dehydration resulting in reduced and variable absorption. Fentanyl transdermal patches have a slow onset of action contributing to difficulty in dose titration.

• Drugs that should not be used for treatment of pain during end-of-life care are listed in Table 4-1.

Table 4-1 Drugs NOT Recommended for Treatment in End-of-Life Care




Meperidine has a short duration of

analgesia (e.g., 2-3 hours) and Its

rmetabolite, normeperidine, may

accumulate with repeated dosing,

especially in geriatric patients,

resulting in neurotoxicity


Propoxyphene's metabolite,

norpropoxyphene, may accumulate

with repeated dosing, especially

in geriatric patients, resulting in


Opioid agonist

The risk of precipitating withdrawal

antagonists (e.g.,

symptoms in opioid dependent


patients in addition to their ceiling


dose and possible induction


of psycho mimetic effects (e,g.r

dysphoria, delusions, hallucinations}

make this group of analgesics

inappropriate for use

Anxiolytics (e.g.,

These agents have not shown benefit


in patients with nociceptive pain.


The added sedative properties

lorazepam) and

of these agents compromise

other sedative-

neurolog i assessment n pat enti.

hypnotic drugs

receiving opioids

(e.g., barbiturates)

• Different types of pain may require other analgesics or adjuvant medications. For example:

• Visceral pain (nociceptive pain that is caused by stretching or spasms of visceral organs such as the GI tract, liver, and pancreas) should be treated with the standard WHO step approach to pain, with the addition of anticholinergic agents or, if inflammation is associated with the pain, corticosteroids.

• Bone pain (a common metastatic site of various cancers) is best treated with NSAIDs or corticosteroids in addition to standard opioid therapy.

• Neuropathic pain (pain caused by damage to the afferent nociceptive fibers) can be managed with tricyclic antidepressants, antiepileptic drugs, tramadol, or N-methyl-d-aspartate antagonists such as ketamine. Methadone is an opioid mu agonist that has a role in neuropathic pain given its added N-methyl-D-aspartate antagonist activity.

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