A synopsis of AFPs Pharmacologic Management of Pain at the End of Life"

A synopsis of:
Pharmacologic Management of Pain at the End of Life
HUNTER GRONINGER, MD, Clinical Center, National Institutes of Health, Bethesda, Maryland JAYA VIJAYAN, MD, Holy Cross Hospital, Silver Spring, Maryland
Am Fam Physician. 2014 Jul 1;90(1):26-32.

     Managing pain control at the end of life is critical towards maintaining quality of life. Pain should be assessed frequently with either a pain scale, checking functional level, or through pain related symptoms (facial grimacing, tachycardia, tachypnea, or restlessness). The WHO has developed a pain ladder here, which illustrates that non-opioid medications should be used first, with stronger medications added systematically until relief is achieved. The first medication used is typically acetaminophen. Ingesting more than 4000 mg/day can cause liver toxicity. Patients taking NSAIDs for more than a week or longer should also be prescribed a PPI.
     Opioids are usually the most effective medication for pain relief. Fear of creating addiction or dependence is not a reason to withhold this medication, especially in EOL care. Side effects include sedation and respiratory depression. Patients who need dosages around the clock should be given long-acting or controlled release preparations. Short acting doses (of 10-20% of the total daily dose) can be used PRN for breakthrough pain. If identified, the dose can be given before the etiology of the pain. When changing an opioid medication, the new drug should be reduced by at least 25% and then titrated up if needed. If a patient has a hard time swallowing medication, concentrated elixirs, creams, patches, suppositories, or pumps may be considered.
     Visceral pain can be reduced when opioids are combined with NSAIDs (for inflammation) or octreotide (for obstruction). Neuropathic pain can be controlled with TCA's, SSRI's, anticonvulsants, Na channel blocking antiarrhythmics, and gabapentinoids. Since these medications may need to be titrated, opioids or tramadol can used as a bridge. Methadone can be used for neuropathic pain, but due to its complexity, only experienced physicians should prescribe it .