The end of life is often characterized by a reduced level of consciousness or complete lack of consciousness. This can make assessments of pain very challenging. If a patient is not alert enough to communicate, nonverbal signs or cues must be used to determine if the patient is experiencing pain and to what degree an analgesic approach is effective. Signs of discomfort that are accompanied by more rapid breathing or heart rate should be taken more seriously. Opioids are often valuable for providing effective analgesia at the end of life, and opioid formulations are available in such variety in the U.S. that, typically, a pain regimen can be tailored to each patient. Because there is great between-patient variability in response to particular opioid agents no specific agent is superior to another as first-line therapy. Opioid-related side effects must be considered in advance of treatment and steps must be taken to minimize these effects to the extent possible, since adverse effects contribute significantly to analgesic nonadherence. This is particularly true for constipation and sedation. A stimulant, such as methylphenidate or dextroamphetamine, might be added to offset sedative effects, typically starting at a dose of 5 to 10 mg once or twice daily. Other adverse effects, including respiratory depression, are greatly feared and may lead to clinician under-prescribing and reluctance by patients to take the medication, despite the rarity of this event in persons with cancer. 183 Despite this fear, studies have revealed no correlation between opioid dose, timing of opioid administration, and time of death. 184 A wide range of complementary and alternative therapies (CAT) are commonly used in end-of-life care. CAT interventions are aimed at reducing pain, inducing relaxation, and enhancing a sense of control over the pain or the underlying disease. Breathing exercises, relaxation, imagery, hypnosis, and other behavioral therapies are among the modalities shown to be potentially helpful to patients. 185 Psychosocial interventions for end- of-life pain may include cancer pain education, hypnosis and imagery based methods, and coping skills training. Educational programs are one of the most common interventions to address cancer pain barriers, and current studies provide high-quality evidence that pain education is feasible, cost- effective, and practical in end-of-life settings. 186 Conclusions Managing pain is particularly challenging in an era when society is grappling with an epidemic of opioid misuse and overdose. This learning activity has reviewed an evidence-based path forward,
based on a biopsychosocial model of pain, and an emphasis on holistic assessment, individualized treatment planning, and multi-modal therapeutic approaches. Physicians and caregivers need to base pain treatment plans on realistic functional goals and the level of pain management needed to reach those goals using a shared decision-making approach. As detailed in this activity, chronic pain syndromes respond differently to available pharmacologic and non-pharmacologic treatments, but, in general, non-drug options (which can be as effective as drug options) should be tried first when possible. When drug options are considered, it is important to maximize non-opioid options before prescribing opioids. For selected patients requiring opioids, the risk of long-term opioid treatment should be minimized through patient education, screening of high-risk patients for OUD, continuous monitoring, use of alternative non-opioid options, and careful tapering when appropriate. Since much acute pain is self-limiting and remits with healing (typically within a month), helping patients frame expectations about acute pain and pain relief can provide reassurance and reduce fear, worry, and distress. Multimodal approaches should be used to manage acute pain, combining non-drug (e.g. interventional procedures, physical rehabilitation, and psychological support) as well as appropriate drug-based options. Opioid analgesics should be reserved for severe pain that does not respond to all other approaches, and then should be used at the lowest doses, and shortest durations, appropriate for the pain intensity expected with the precipitating event. This activity has laid out the evidence supporting these conclusions and provides the basis for improved treatment and reduced risk, both for patients and society at large.
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