Pharmacologic Management of Pain at the End of Life



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Am Fam Physician. 2014 Jul 1;90(1):26-32.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Related editorial: Beyond Analgesia in Palliative Care and End-of-Life Interventions

  Patient information: See related handout on managing pain at the end-of-life, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Although many patients experience debilitating pain at the end of life, there are many options to improve analgesia and quality of life. Pain assessment using a validated tool, with attention to patient function and specific goals, helps tailor individual treatment plans. The World Health Organization pain ladder offers a stepwise guideline for approaching pain management. However, for many patients with terminal illness, strong opioids are necessary for efficient and effective analgesia. Equianalgesic dosing tables and expert guidelines aid in initiating, monitoring, and adjusting doses of oral and parenteral opioids. Clinicians should feel comfortable administering a repeat dose after the time to peak analgesic effect if the patient is still in pain. In patients with constant pain, using scheduled long-acting opioids may significantly improve pain control. Among pain subtypes, visceral pain management usually requires multiple drugs. Neuropathic pain responds well to adjuvant pharmacotherapies, such as anticonvulsants or antidepressants, in addition to opioids. Opioid-induced hyperalgesia can occur with any dose of an opioid, but is more common with higher doses of parenteral morphine and hydromorphone. With appropriate counseling, most patients with a history of substance abuse will comply with a pain treatment plan.

Many persons experience significant pain in the final months of life.1,2 In addition to wanting to preserve as much quality of life as possible, most patients express a preference to die outside of institutional settings.3 A key element to achieving these goals is adequate pain control. Despite advances in understanding pain physiology and available pharmacotherapies, many patients with terminal illnesses, such as cancer, report untreated or undertreated pain.4

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comment

Pain should be assessed regularly in all patients with terminal illness, including those with cognitive impairment.

C

5, 7

Recommendation from expert consensus and systematic review

In patients with constant pain that responds to opioids, scheduling opioids with adequate breakthrough doses provides optimal analgesia.

C

19, 21, 29

Recommendations from expert consensus, systematic review, and low-quality randomized controlled trials

When patients develop opioid tolerance, rotating to an alternative opioid may improve analgesia.

B

33

Systematic review of uncontrolled prospective trials and case reports

Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids are first-line therapies for neuropathic pain. Opioids are also effective.

A

4245

Systematic reviews of prospective randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comment

Pain should be assessed regularly in all patients with terminal illness, including those with cognitive impairment.

C

5, 7

Recommendation from expert consensus and systematic review

In patients with constant pain that responds to opioids, scheduling opioids with adequate breakthrough doses provides optimal analgesia.

C

19, 21, 29

Recommendations from expert consensus, systematic review, and low-quality randomized controlled trials

When patients develop opioid tolerance, rotating to an alternative opioid may improve analgesia.

B

33

Systematic review of uncontrolled prospective trials and case reports

Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids are first-line therapies for neuropathic pain. Opioids are also effective.

A

4245

Systematic reviews of prospective randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

BEST PRACTICES IN END-OF-LIFE CARE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

Recommendation Sponsoring organization

Do not delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.

American College of Emergency Physicians

Do not delay palliative care for patients with a serious illness who have physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment.

American Academy of Hospice and Palliative Medicine


Source: For supporting

The Authors

HUNTER GRONINGER, MD, is a staff clinician in the Department of Pain and Palliative Care at the Clinical Center, National Institutes of Health in Bethesda, Md.

JAYA VIJAYAN, MD, is a palliative care consultant at Holy Cross Hospital in Silver Spring, Md. At the time the article was submitted, Dr. Vijayan was a staff clinician in the Division of Quality Care and Management at Holy Cross Hospital.

Address correspondence to Hunter Groninger, MD, Clinical Center, National Institutes of Health, Bldg. 10, Rm. 2-1733, Bethesda, MD 20892 (e-mail: hunter.groninger@nih.gov). Reprints are not available from the authors.

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