pain management in palliative care

Epidemiology

• pain is prevalent, debilitating & poorly undertreated in patients near the end of life
• 60-90% of patients with advanced cancer experience moderate to severe pain during their illness
• 50% of patients' pain is poorly controlled, despite the fact that adherence to simple pain management guidelines can control pain in > 80% of dying patients

Management

• hydromorphone, fentanyl, methadone*, buprenorphine, hydrocodone show minimal pharmacokinetic changes in patients with renal failure

* methadone has a prolonged 1/2 life

• respiratory depressant effects can persist for 36-48 hours
• prolongs QTc, requires EKG to monitor QTc
• interaction with other drugs that prolong QTc

Notes

Barriers to optimal pain management:

• inability to control pain in patients with advanced illness reflects a complex interplay of patient, physician & system- of-care factors
• patient factors
  • fear of side effects, addiction, overdose, or worsening pain reflects disease progression
  • desire not to burden others, including perception of pain as a sign of weakness
  • belief that severe pain is an in an inevitable part of the dying process
  • fear that if the pain is treated early, they will run out of options for treatment in the future
  • fear of adverse effects of analgesics
  • fear that increasing pain means the disease is getting worse
  • concern about being a 'good' patient
• physician factors
  • physicians routinely underestimate patients' pain
  • fear - of addiction, abuse
  • pain as a sign of failure of medical care
• system-of-care factors
  • organizational structure often discourages continuity of care
  • underdeveloped systems for routine pain assessment & followup

Ethical issues in pain management:

• principle of double effect

Additional terms

• pain [odyn-]
• palliative care
• World Health Organization (WHO) pain ladder