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Pain Management

People often express more fear about dying in pain, than death itself. In fact, researchers have consistently demonstrated that pain control is often inadequate for those who are dying. However, pain is not simple to define. Two people with similar conditions may react very differently, with 1 person reporting pain at level "3" on a 1-10 scale and another reporting pain at level "8." How then do healthcare workers determine the level of pain? Is one person right and the other wrong about the level of pain? Is there a right or a wrong at all? Should healthcare workers worry about people at the end of life becoming “addicted?”

These are not simple questions, but a good starting point is: Assume that pain is what the person experiencing it says it is, taking into consideration that many physical, psychological, social, and spiritual issues can affect pain. Despite the availability of pain medicines, many people still die with their pain uncontrolled, and that is a failure of the healthcare providers. There are many drugs that can and should be used to control pain and symptoms:

Analgesics
Adjuvant analgesics/ other medications
Sedatives/ nerve blocks

Instant Feedback:

Pain is what the person experiencing it says it is.

Analgesics:
The World Health Organization (WHO) has developed a “pain ladder” that provides guidelines for administration of analgesia for severe pain. The WHO advises administration of medications in the following order if pain occurs.

Level 1: mild pain, use non-opioids, such as ASA, acetaminophen, or nonsteroidal anti-inflammatory agents (NSAIDs) like ibuprofen
Level 2: pain persists from mild to moderate, use mild opioids, such as Percocet, Tylenol #3, Vicodin, or Oxycodone
Level 3: pain persists or becomes moderate to severe, use strong opioids, such as morphine, dilaudid, or oxycontin

Adjuvant drugs may be added to calm fears or anxiety or control side effects of medications. The WHO and other researchers recommend that drugs be given around the clock (every 3 to 6 hours) to prevent breakthrough pain rather than “on demand” to prevent the recurrence of pain. This approach to pain control is 80% to 90% effective. If pain continues to break through, the dosage of medication needs to be retitrated upward or other methods, such as nerve block, need to be considered. As body systems begin to fail, especially renal and hepatic failure, medications may need to be altered, with shorter acting opioids or rotation of opioids. If patients are not able to speak and express the degree of their pain, then indications of suffering, such as moaning, or stiffening when moved, should be considered as evidence of pain.

Innovations in End-of-Life Care, an international journal of leaders in end-of-life care, has provided a number of useful tools on it's website. Medication references, include “Opioid Reference Table,” “Adjuvant Analgesics,” and “Side Effects Management.” Click here to download in PDF format.

Instant Feedback:

If followed, the “pain ladder” developed by the WHO is an effective method of controlling end of life pain.

Adjuvant analgesics/other medications:
As well as primary pain analgesics, patients may frequently also need adjuvant medications for various unrelieved symptoms, or medications for side effects:

NSAIDs: for aching, dull, localized tenderness in bones
Corticosteroids: for deep, boring referred or poorly localized visceral pain, as well as spinal cord and nerve compression.
Antidepressants: for burning tingling, depression
Anticonvulsants: for shooting, chronic neuralgias
Anti-cholinergics: colic, cramping abdominal pain, bladder spasms
Anti-emetics: for nausea
Stool softeners: for bowel regimen
Anti-anxiety medications: for anxiety, delirium, hallucinations
Anti-pruritics: for itching
H2 receptor antagonists: for excess stomach acid

Instant Feedback:

Adjuvant and other medications are rarely needed.

Sedatives/Nerve block/Neuraxial analgesia:
Sedatives may be needed if pain remains uncontrolled with analgesia. Because patients will no longer be conscious when they are sedated, ideally the possibility of using sedation should be discussed in advance with the patient and family members. They then have the opportunity to say good-bye or reach closure. Family and other loved ones may react with grief at the loss of personal communication, and they need preparation and support to deal with their own pain. Others may be relieved that the patient is no longer suffering and find a sense of peace in that knowledge.

Sometimes neural ablation (nerve block) can relieve pain for some conditions, and this may allow the patient to have relief of suffering and still retain consciousness as long as possible. More commonly, neuraxial analgesia has been used with intraspinal therapy (intrathecal and epidural) to relieve intractable pain.

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Intractable pain may require the use of sedation, neural blocks or neuraxial analgesia.