Palliative Care

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.
  • Not Routinely Used: Codeine, Tramadol, Tapentadol due to efficacy and predictability issues
• 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.