☛ the use of analgesics for the treatment of acute pain is the same as for non-palliative care patients
☛ it is the treatment of chronic pain that is often poorly managed and requires a different approach
CHOICE OF DRUG
The selection of which drug or drugs to use involves
☛ selecting a drug appropriate for the type of pain
☛ selecting a drug appropriate for the severity of pain
☛ using combinations of drugs, not combined preparations
☛ following the analgesic ladder
☛ using adjuvant analgesics
☛ never using placebo
Drug strength
☛ as it is important that pain be controlled as quickly as possible, it is preferable to start with a strong analgesic and subsequently wean the patient to a weaker drug
Type of pain
☛ different pains respond to different analgesics:
Drug Combinations
☛ when prescribing more than one drug, the different drugs should be given independently and compound preparations avoided
☛ if it is necessary to escalate the dose of one of the drugs in a combined preparation, the dose of the second will also be increased and may cause unwanted toxicity
The analgesic ladder
☛ if the prescribed drugs do not produce adequate analgesia, treatment is escalated in an orderly manner
↳ from non-opioid to weak opioid to strong opioid, as illustrated in the World Health Organization’s "Analgesic Ladder"
☛ non-opioid analgesic should be continued when opioid drugs are commenced, as their action can be complementary and allow lesser doses of opioids to be used
☛ adjuvant analgesics should be used whenever indicated
WHO Analgesic Ladder
Placebo
☛ there is no place for the use of placebo medications in the treatment of chronic pain in palliative care
☛ it is unethical and will lead to distrust if discovered by the patient
☛ whether or not a response occurs provides no useful information
DRUG ADMINISTRATION
The principles of analgesic administration for chronic pain are
☛ give in adequate dosage
☛ titrate the dose for each individual patient
☛ schedule administration according to drug pharmacology
☛ administer on a strict schedule to prevent pain, not PRN
☛ give written instructions for patients on multiple drugs
☛ give instructions for treatment of breakthrough pain
☛ warn of, and give treatment to prevent, adverse effects
☛ keep the analgesic program as simple as possible
☛ use the oral route wherever possible
☛ review and reassess
Dose
☛ the selected drug or drugs are prescribed in a dose adequate to relieve the pain
☛ the dose needs to be titrated against the pain for each individual patient
Schedule
☛ drugs are given according to a strict schedule, determined by the duration of drug action, in order to prevent the recurrence of pain — Not PRN
☛ drugs given on an "as required" basis or pro re nata (PRN) usually results in poor pain control
Instructions for breakthrough pain
☛ it is essential to give instructions for the treatment of breakthrough pain
↳ it is reassuring
↳ avoids the despair that occurs if an analgesic program is ineffective
↳ helps the patient feel in control
Keep it simple
☛ avoid multiple analgesics
☛ it is usually possible to simplify the analgesic program, even for patients with severe pain
Oral
☛ Oral medication should only be abandoned if the patient is unable to take or retain them
Reassessment
☛ continued reassessment is necessary and a number of dose modifications are often needed before optimal pain control is achieved
↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf
