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10 Articles in Volume 9, Issue #4
Application of Spinal Segmental Physiology to Evaluating Chronic Pain
Dental Consequences of Pain Management
Facility Profile: Casa Palmera
Intellectual and Moral Tasks in Intersection—Part 2
Milnacipran: A New Treatment Option for Fibromyalgia
Neuroma Pain of the Foot Successfully Managed with Laser Therapy
Opioid Treatment Longevity Study: Interim Report
Pain Management in a Palliative Care Setting
Precursor Amino Acid Therapy
Prolotherapy for Sacroiliac Joint Laxity

Pain Management in a Palliative Care Setting

Pain management strategies in the palliative care setting must take into account barriers to appropriate pain management.

Palliative care is any form of medical care or treatment that concentrates on reducing the severity of disease symptoms rather than striving to halt, delay, or reverse the progression of the disease itself, or provide a cure. The goal is to prevent and relieve suffering and to improve the quality of life for people facing serious, complex illness. It should not be confused with hospice care, which delivers palliative care to those at the end of life.1

While palliative care may seem to offer an incredibly broad range of services, the goals of palliative treatment are extremely concrete:

  • relief from suffering
  • treatment of pain
  • treatment of other distressing symptoms
  • psychological and spiritual care
  • daily living support system
  • support system for the patient’s family2

Recognizing, Monitoring and Documenting Pain

Pain, acute or chronic, is an element of the large majority of medical ailments that physicians see on a daily basis. Back pain alone has been suggested to affect “up to 84 percent of adults…at some point in their lives” and back pain still exists as “the second most common symptom-related reason for physician visits in the United States.”3 In addition, it is important to consider that pain can be a major contributing factor in the morbidity and mortality associated with many medical conditions—often being “associated with progressive decline in functioning and other complications such as weight loss.”4 It is therefore clear that pain is an important factor to address in the comprehensive care of patients within all fields of medicine.

It seems appropriate then, that physicians—whose primary objective is to “apply, for the benefit of the sick, all measures [that] are required,”5—would seek to make use of all available tools to address this prevalent and problematic element of patient suffering. However, even with a clear need for adequate treatment of pain and pain-associated morbidities, the needs of patients across the spectrum of healthcare are not being met. Even with “moderate to severe chronic pain [being] experienced by at least 70 percent of patients with advanced cancer,”6 it is reported that “under-treatment of cancer pain has been estimated to be as high as 40 percent.”7 Beyond cancer, “studies demonstrate poor control of post-operative and trauma pain…and chronic, non-cancer pain.”8 Therefore, there is a dilemma regarding pain recognition and management that must be examined and acted upon in order to serve the large population of patients who suffer from pain on an acute or chronic basis.

In order to ensure that pain is being properly addressed, it is essential to have an adequate system for initially recognizing pain so that it may be treated promptly. A system where pain is monitored and documented in a clear way—with a history of the time of onset, intensity of the pain, any alleviating or discomforting factors, and the progression of the symptoms—is an invaluable tool for creating continuity of care of patients in many different clinical settings. However, “assessment of pain intensity alone is insufficient and may lead to unsafe care.”9 Rather, one must gather information regarding the “impact of pain on physical [as well as] emotional function,” and use that to guide an individually-tailored treatment plan because, again, pain must be defined by the total subjective experience of the specific patient being monitored and treated.10 This often includes not only the impact of pain on the patient themselves, but also on family members and others who they interact with. Further, it is important to assess “outcomes of prior and existing analgesic therapies,” so that a more directed management approach can be taken. Overall, an all-encompassing history regarding the experience of the patient’s pain is an excellent initial step at providing efficient pain management.

Pain Management Planning

In an effort to provide comprehensive health care for those in need, it is also important for clinicians to encourage the patient to contribute to the development of their own personal management plan. Studies have suggested that “patients engaged in collaborative care, shared decision-making with their providers, and chronic disease self-management have improved health outcomes.”11 It is incumbent on the physician to involve the patient in their own healthcare so that patients become educated regarding their condition and the options that are available to them. It is the emphasis on the personalized nature of management that is essential for efficient delivery of pain management.

“It is incumbent on the physician to involve the patient in their own healthcare so that patients become educated regarding their condition and the options that are available to them.”

Once a treatment plan has been formulated, it is crucial that the treatment pattern be followed and constantly monitored to ensure that goals are being met as judged by the physician, as well as the patient. Often, this begins with an understanding that “although efforts can lower the percentage of patients with moderate to severe acute [pain] and cancer pain, the elimination of pain is, in many cases, impossible.’12 Instead, it is more important for patients to realize that the primary goal of treatment of pain is to use treatments that are both efficient and safe. With a treatment plan in place, it is then important to constantly evaluate and reassess the efficacy of treatment and investigate any problems that arise. In this way, physicians “ensure safety and efficacy…[with] quality improvement efforts [fostering] active patient and family engagement in the treatment plan.”13 With such care taken to ensure a comprehensive and safe plan, treatment of pain can be successful.

Pain Management Delivery Issues

At this point, we are still faced with an overwhelming void in the delivery of appropriate pain management due to several key issues, which must be understood before any measures can be taken to overcome them. Among these barriers to effective pain management lies “the combined effects of clinician’s lack of knowledge, attitudes that diminish the perceived importance of pain management, and fear of hastening death; patient underreporting and therapeutic non-adherence; patient or family belief in the inevitability of pain or fear of addiction or tolerance; and system-wide impediments to optimal analgesic therapy.”14 In addition, studies suggest that “minority status, female sex, and a history of substance abuse each increase the risk of under-treatment.”15 Furthermore, “among institutionalized elderly patients with cancer, under-treatment has been linked to age greater than 85…impaired cognition, and the requirement for multiple medications.”16 It is clear from the multiple barriers that impede adequate treatment of pain that an effort to correct this inefficiency of healthcare delivery is absolutely essential.

One area of medical practice which has attempted to circumnavigate these pitfalls of under-treatment is palliative care, a specialty of medicine in which the role of the caregiver is to be sensitive to and “focused on the comprehensive management of the physical, psychological, social, and spiritual needs of patients with serious or life-threatening diseases.”17 Palliative care is intended to provide a complete model of care that is both medicinal and elemental in the needs of human beings, especially those faced with chronic or terminal illnesses. With the overriding goal of the reduction of suffering, palliative care recognizes that, at the end of life, “the suffering that characterizes the period before death can be related, at least in part, to the experience of unrelieved symp-toms… [with] pain among the most prevalent of these symptoms.”18 Operating under an understanding of the concept of “total pain,” which “recognizes that pain at the end of life encompasses more than the ‘physical’ pain associated with the physical ravages of disease, and [includes] emotional, social, and spiritual aspects,” palliative care aims at making patients and their families comfortable and informed.19

An important consideration in the delivery of palliative care is that, as stated by the World Health Organization (WHO), “pain management at the end of life is the right of the patient and the duty of the clinician.” It is this founding principle that allows palliative care to challenge the classical notion of under-treatment of pain, motivating their care with both a moral as well as a legal support. In 1997, the supreme court case of Vacco v. Quill ruled that “a patient who is suffering from a terminal illness and who is experiencing great pain has no legal barriers to obtaining medications from qualified physicians to alleviate suffering, even to the point of causing unconsciousness and hastening death.”20 It is therefore, not only legally protected to treat pain, but actually out of the scope of good practice if one fails to practice adequate pain management, especially for those suffering from chronic or terminal illness.

A key aspect of palliative medicine lies in the idea that the goals of analgesic therapy for pain, especially in the context of advanced illness, may change dramatically, but with open and honest communication between patient and physician, patients can be assured of comfortable chronic care, as well as end-of-life care. One must always appreciate the contribution of pain specifically to suffering and aim to alleviate discomfort—be it physical or emotional—as the primary goal of treatment.

Prescribing Guidelines in Palliative Care

The aim of treatment for patients in pain needing palliative care, is to keep them as comfortable, alert, and as free from symptoms as possible. The number of drugs should be as few as possible, since taking medications may be an effort for the patient. Oral medications are usually satisfactory unless there is severe nausea and vomiting, dysphagia, weakness, or coma.

When prescribing for pain management during palliative care, one principle is to use the “WHO Ladder”21:
Step 1 is used for mild pain, and uses non-opioid analgesics with or without co-analgesics.
Step 2 is utilized for moderate pain, and uses weak opioids plus Step 1 analgesics.
Step 3 is utilized for severe pain, and uses strong opioids plus Step 2 analgesics.
Co-analgesics are drugs that, when used concurrently with analgesics, may contribute significantly to pain relief. The following are examples of co-analgesics:

  • NSAID (ibuprofen, naproxin, diclofenac, ketorolac, rofecoxib)
  • Steroids (dexamethasone)
  • Antidepressants (amitriptyline, clothsepin)
  • Anticonvulsants (carbamazapine, sodium valporate, clonazapam, gabapentin)
  • Antispasmodics (baclofen, diazapam, hyoscine, butylbromide)
  • Psycho-tropics (diazapam, levomeprozamine)
  • NMDA Receptor Antagonist (ketamine)22

Prior to instituting drug treatment for nausea and vomiting, exclude or actively treat any potentially reversible causes of nausea, such as: drugs, chemotherapy, radiotherapy, constipation, hypocalcemia, renal or hepatic failure, small or large bowel obstruction, gastritis, cough, and/or anxiety. Treat the underlying cause whenever possible, otherwise manage the problem symptomatically. Antiemetics should be used in accordance with the likely etiology of the nausea and/or vomiting.23

With treatment for chronic pain, and other conditions in palliative care, we should be aware of guidelines for prescribing laxatives when necessary. Many patients undergoing palliative care may have multiple contributing factors for needing laxatives. When constipation occurs, it can cause abdominal pain which is unrelated to the pain resulting from the disease. These factors may include:

  • immobility
  • poor intake and debility
  • weakness
  • drugs (opioids and anti-cholinergics)
  • hypercalcemia
  • dehydration
  • bowel obstruction or pseudo-obstruction
  • cord compression or Cauda Equine Syndrome

The management and guideline for prescribing laxatives in palliative care include treating underlying causes when appropriate and possible, and encouraging good oral intake and increased mobility.24

Conclusion

As clinicians, we serve a moral and legal code to provide comfort to those in need and to ensure delivery of such comfort in a comprehensive and safe manner. Although there are numerous barriers to efficient delivery of pain management, an organized effort to educate physicians and patients regarding use of pharmacologic and non-pharmacologic methods of treatment would serve to dispel much of the rumors and concerns that surround control of pain today. It is therefore essential that as we move forward in health care, we do not lose sight of its mission, the obligation to provide a listening ear and an eager hand, and to care for those in need.

When patients are released from hospitals to a nursing home or long term care facility for palliative care, the staff receives considerable medical information including the need for pain medication. Pain management strategies in the palliative care setting must take into account barriers to appropriate pain management such as the unwillingness of many nursing homes to store opiates, inadequate staff to monitor frequent analgesia administration, and the inadequate knowledge and failure of many physicians to use analgesic agents aggressively. Failure to prevent and/or treat pain effectively is no longer acceptable and should be considered an indicator of poor quality medical care.

Last updated on: December 20, 2011
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