The first step in managing a patient's pain is taking a total pain assessment. There are numerous pain scales to assess pain. Many institutions use a numerical rating pain scale that asks patients to rate their pain intensity on a zero to ten scale, with 0 being none and ten the most severe. Others are more detailed and tested for reliability and validity. Here are the names of the most common pain assessment tools:
Go to https://www.verywellhealth.com/pain-scales-assessment-tools-4020329 for more detailed information about these scales (Jacques, 2020).
The pain must be treated immediately and consistently; otherwise, it increases in intensity. Pain medication should not be withheld because of fear of addiction. Here is the World Health Organization's pain ladder step-care approach.
Step 1. Start with a nonsteroidal anti-inflammatory drug (NSAID). Examples of NSAIDs include over-the-counter medications like ibuprofen and stronger NSAIDs that your healthcare provider may prescribe. An alternative to NSAIDs for step 1 pain is acetaminophen.
Step 2. If pain continues or gets worse, from mild to moderate, your healthcare provider may prescribe a weak opioid medicine, like hydrocodone. A weak opioid may be combined with a nonopioid pain reliever like Percocet, a combination of oxycodone and acetaminophen.
Step 3. If pain continues or gets worse, your healthcare provider may prescribe a more potent opiate. Examples of strong opioids include morphine and fentanyl. https://www.hopkinsmedicine.org/health/wellness-and-prevention/palliative-care-methods-for-controlling-painWhat about addiction?
Here are general clinical recommendations by Groninger (2014) for pain management with evidence ratings.
Clinical recommendation |
Evidence rating |
Comment |
Pain should be assessed regularly in all patients with a terminal illness, including those with cognitive impairment. |
C |
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 |
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 |
A 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 |
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 https://www.aafp.org/afpsort | ||
Fentanyl is a synthetic opioid similar to morph but 50 to 100 times more potent. It can be administered through a patch, which makes it particularly helpful with swallowing issues, nausea, vomiting, or fear of needles. 317627240 https://www.drugabuse.gov/publications/drugfacts/fentanyl
What about addiction?
The most common drugs that can lead to dependency and addiction are opioids, like oxycodone, hydrocodone, hydromorphone, and meperidine. 97% of people who use prescription drugs for pain relief will not have a problem with opioids. The patients that have had issues with substance addiction, such as alcohol or nicotine, are more at risk for addiction. Patients who are prescribed opioids for long-term use should not reduce addiction risk by cutting down on their dose. The pain can worsen, requiring even more medication than usual (Groninger et al., 2014).
What about alertness?
In palliative care, patients are typically more active than patients receiving hospice care. There is often the need to maintain a balance between reasonable pain control and being alert and oriented.
Instant Feedback:
Pain is what the person experiencing it says it is.
Analgesics:
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 avoid the recurrence of pain. This approach to pain control is 80% to 90% effective. If pain continues to break through, medication dosage needs to be re-titrated upward or other methods, such as nerve block, need to be considered. As body systems begin to fail, predominantly renal and hepatic failure, medications may need to be altered, with shorter-acting opioids or rotation of opioids. If patients cannot 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.
Adjuvant drugs can be given with Fentanyl patches when there is breakthrough pain. The dose of the Fentanyl patch is then increased to address the amount of breakthrough pain when it is changed.
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 medicines for side effects:
Instant Feedback:
Adjuvant and other medications are rarely needed.
Palliative sedation (pS) is indicated in the presence of end-stage disease with treatment-refractory symptoms not tolerable for the patient. A study by Hopprich A., et al,. included 34 terminal cancer patients receiving pS for terminal restlessness (56%), dyspnea (39%), pain (32%), psychological distress (15%), agitated delirium (9%), vomiting (3%) and bleeding (3%). The most applied medication was midazolam (94%), sometimes combined with neuroleptics (44%) and propofol (15%), and 91% of the patients additionally received opioids. Physician assessment revealed complete symptom relief in 12 patients (35%), very strong symptom relief in 20 patients (59%) and moderate symptom relief in 2 patients (6%). Palliative sedation started in the median 27.5 hours before death.
Neuraxial analgesia is "considered for use in patients who have resistant intractable pain that fails to respond to other treatment options or pain that responds to analgesia but for which the doses required result in unacceptable side-effects. Neuraxial opiods can be considered for both chronic non-malignant pain and chronic cancer-related pain. Effectiveness in chronic non-malignant pain and cancer pain is exerted through the use of either single-agent drugs (opioids) or a combination of drugs: opioids, local anaesthetics and other drugs such as clonodine and ziconotide. Complications of long-term continuous infusion therapy are related to the insertion process (haematoma), the mechanical device (both pump and catheter) and the long-term effects of the drugs. Patients will require ongoing ambulatory monitoring and supportive care" (Farquar-Smith, 2012).
Nerve ablation is the "destruction (also called ablation) of nerves is a method that may be used to reduce certain kinds of chronic pain by preventing transmission of pain signals. It is a safe procedure in which a portion of nerve tissue is destroyed or removed to cause an interruption in pain signals and reduce pain in that area. Nerve ablation can be done in different ways. For example, it can be done using heat, cold, or chemicals. What the procedure is called depends on how it is done. For example, it may be called radiofrequency ablation, cryoablation, neurotomy, or rhizotomy" (Healthwise, 2019).
Instant Feedback:
Intractable pain may require the use of sedation, neural blocks, or neuraxial analgesia.
References
Albert, R.H. (2017). End-of-Life Care: Managing Common Symptoms. Am Fam Physician. 95(6), 356-361.
Farquhar-Smith, P., & Chapman, S. (2012). Neuraxial (epidural and intrathecal) opioids for intractable pain. British journal of pain, 6(1), 25–35. https://doi.org/10.1177/2049463712439256
Groninger, H. & Vijayan J. (2014). Pharmacologic management of pain at the end of life. Am Fam Physician. 90(1),26-32.
Hopprich A, Günther LD, Laufenberg-Feldmann R, Reinholz U, Weber M. Palliative sedation at a university palliative care unit--a descriptive analysis]. Dtsch Med Wochenschr. 2016 Apr;141(8):e60-6 https://pubmed.ncbi.nlm.nih.gov/27078251/
Jacques, E. (2020). Ten common types of pain scales. Everywell Health. https://www.verywellhealth.com/pain-scales-assessment-tools-4020329
Nerve Ablation for Chronic Pain. Healthwise Staff. 2019
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