____________________________________________ Assessment and Management of Pain at the End of Life
ORAL ADJUVANT ANALGESICS
Drug Class
Drug
Typical Starting Dose 100–300 mg once daily 25–75 mg twice daily 50–100 mg twice daily
Usual Effective Dose
Anticonvulsants
Gabapentin Pregabalin
300–1,200 mg (2 or 3 divided doses)
75–200 mg (3 divided doses)
Carbamazepine
300–600 mg twice daily 50–200 mg twice daily 150–600 mg twice daily 4–12 mg twice daily 50–150 mg at bedtime
Topiramate
25–50 mg daily
Oxcarbazepine
150–300 mg twice daily
Tiagabine
4 mg at bedtime
Tricyclic antidepressants
Amitriptyline Nortriptyline Desipramine Venlafaxine
10–25 mg at bedtime
Serotonin-norepinephrine reuptake inhibitors Skeletal muscle relaxants
37.5 mg daily
150–350 mg daily
Baclofen
5 mg twice daily 5 mg 3 times daily 400 mg 3 times daily
10–20 mg 2 or 3 times daily 10–20 mg 3 times daily
Cyclobenzaprine
Metaxalone
Not defined Not defined
Corticosteroids Source: [4; 8; 41]
Dexamethasone
1–2 mg
Table 2
that there was limited evidence to support the use of selective serotonin reuptake inhibitors (SSRIs) for neuropathic pain, but one serotonin-norepinephrine reuptake inhibitor, venlafaxine (Effexor), was found to be effective [53]. NONPHARMACOLOGIC INTERVENTIONS Several nonpharmacologic approaches are therapeutic comple- ments to pain-relieving medication, lessening the need for higher doses and perhaps minimizing side effects. These interventions can help decrease pain or distress that may be contributing to the pain sensation. Approaches include palliative radiotherapy, complementary/alternative methods, manipulative and body-based methods, and cognitive/behav- ioral techniques. The choice of a specific nonpharmacologic intervention is based on the patient’s preference, which, in turn, is usually based on a successful experience in the past. Palliative radiotherapy is effective for managing cancer-related pain, especially bone metastases [2; 54; 55]. Bone metastases are the most frequent cause of cancer-related pain; 50% to 75% of patients with bone metastases will have pain and impaired mobility [54]. External-beam radiotherapy is the mainstay of treatment for pain related to bone metastases. At least some response occurs in 70% to 80% of patients, and the median duration of pain relief has been reported to be 11 to 24 weeks [54]. It takes one to four weeks for optimal therapeutic results [54; 55]. However, palliative radiotherapy has become a controversial issue. Although the benefits of palliative radiotherapy are well documented and most hospice and oncology professionals believe that palliative radiotherapy is important, this treatment
According to the Institute for Clinical Systems Improvement, there needs to be shared decision-making with the patient about reducing or eliminating opioids to avoid unnecessary complications from long-term opioid use. This involves following and re-evaluating the patient closely, with dose reduction or discontinuation as needed. (https://www.icsi.org/wp-content/uploads/2021/11/ PalliativeCare_6th-Ed_2020_v2.pdf. Last accessed October 19, 2024.) Level of Evidence : Expert Opinion/Consensus Statement When opioids are prescribed, careful documentation of the patient’s history, examinations, treatments, progress, and plan of care are especially important from a legal perspective. This documentation must provide evidence that the patient is functionally better off with the medication than without [33]. In addition, physicians must note evidence of any dysfunction or abuse. Adjuvant agents are often used in conjunction with opioids and are usually considered after the use of opioids has been optimized [33]. The primary indication for these drugs is adjunctive because they can provide relief in specific situations, especially neuropathic pain. Examples of adjuvant drugs are tricyclic antidepressants, anticonvulsants, muscle relaxants, and corticosteroids ( Table 2 ) [4; 8]. A systematic review found
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MDTX2026
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