Pain
Pain management is a central aspect of palliative care, aiming to improve the quality of life for patients with serious illnesses. Effective pain management in palliative care involves a comprehensive approach that includes pharmacological and non-pharmacological methods. Here’s an outline focusing on the pharmacological aspect:
- Non-Opioid Analgesics:
- Paracetamol: For mild to moderate pain. It’s often used as a first-line agent due to its safety profile.
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Such as
- ibuprofen
- naproxen
- celecoxib
- Effective for pain involving inflammation, but caution is needed regarding gastrointestinal, renal, and cardiovascular risks.
- Opioid Analgesics:
- Normal Renal Function:
- Morphine: The gold standard for severe pain in palliative care.
- Oxycodone: Can be used orally or parenterally.
- Hydromorphone: A potent opioid with fewer side effects in some patients.
- Impaired Renal Function:
- Fentanyl: Available in patches for chronic pain, useful in patients with swallowing difficulties or renal impairment.
- Methadone
- Buprenorphine
- Considerations:
- Regular assessment for side effects like
- constipation -> co-prescribe apperients like lactulose, movicol, coloxyl and senna.
- nausea,
- sedation, and
- respiratory depression
- Titration to the effective dose and consideration of breakthrough pain is important.
- Regular assessment for side effects like
- Not Routinely Used: Codeine, Tramadol, Tapentadol due to efficacy and predictability issues
- Normal Renal Function:
- Adjuvant Analgesics:
- Tricyclic Antidepressants: Such as amitriptyline especially useful in neuropathic pain.
- SNRI Antidepressants: Duloxetine useful in neuropathic pain
- Gabapentanoid Anticonvulsants: Gabapentin and pregabalin are effective for neuropathic pain.
- Antispasmodics: Clonazepam, Diazepam, Baclofen, Hyoscine
- Corticosteroids: Such as dexamethasone, useful for pain due to nerve compression, bone pain, or increased intracranial pressure.
- Bisphosphonates: Used for bone pain, particularly in cancer with bone metastases.
- Topical Analgesics:
- Capsaicin Cream: For localized neuropathic pain.
- Interventional Techniques:
- Nerve Blocks: For specific nerve pain syndromes.
- Spinal Analgesia: Epidural or intrathecal analgesia for refractory pain.
- Radiotherapy: For bone pain
- Individualized Approach:
- Tailoring Treatment: Based on the type of pain, patient’s overall condition, response to previous medications, and side effect profiles.
- Combination Therapy: Often necessary for adequate pain control. For example, combining opioids with adjuvant analgesics for neuropathic pain.
- Monitoring and Adjustments:
- Regular Pain Assessment: Using appropriate pain scales.
- Monitoring Side Effects: And adjusting treatment accordingly.
- Breakthrough Pain Management: Fast-acting pain relief for sudden, intense pain episodes.
- Non-Pharmacological Approaches:
- Complementary therapies such as massage, acupuncture, physiotherapy, psychological support, and relaxation techniques can be valuable adjuncts to pharmacological treatment.
- End-of-Life Care:
- In the terminal phase, maintaining comfort with adequate analgesia, often with continuous morphine/midazolam infusion and managing other symptoms is the priority.
In palliative care, pain management is highly individualized, focusing on patient comfort and quality of life. It requires ongoing assessment and a dynamic approach, adapting to the changing needs of the patient. Collaboration among healthcare providers, including palliative care specialists, is crucial for optimal pain management.