Assessment and Management of Pain at the End of Life _ ___________________________________________
Tolerance to other side effects, such as nausea and sedation, usually develops within three to seven days. Some patients may state that they are “allergic” to an opioid. It is important for the physician to explore what the patient experienced when the drug was taken in the past, as many patients misinterpret side effects as an allergy. True allergy to an opioid is rare [8]. Opioid rotation may also be done to reduce adverse events. 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 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 approach is offered at approximately 24% of Medicare-certified freestanding hospices, with less than 3% of hospice patients being treated [56; 57; 58]. As previously noted, reimburse- ment issues present a primary barrier to the use of palliative radiotherapy [56; 57; 58]. Among other barriers are short life expectancy, transportation issues, patient inconvenience, and lack of knowledge about the benefits of palliative radiotherapy in the primary care community [55; 56; 57; 59]. One study found that more than half (54%) of people use complementary/alternative medicine therapies at the end of life [60]. The most commonly used therapies are massage, music, relaxation techniques, and acupuncture [60; 61; 62; 63; 64]. Massage, which can be broadly defined as stroking, compres- sion, or percussion, has led to significant and immediate improvement in pain in the hospice setting [65]. Both mas- sage and vibration are primarily effective for muscle spasms related to tension or nerve injury, and massage can be carried out with simultaneous application of heat or cold. Massage may be harmful for patients with coagulation abnormalities or thrombophlebitis [12]. Focused relaxation and breathing can help decrease pain by easing muscle tension. Progressive muscle relaxation, in which patients follow a sequence of tensing and relaxing muscle groups, has enabled patients to feel more in control and to experience less pain and can also help provide distraction from pain [12]. This technique should be avoided if the muscle tensing will be too painful. Acupuncture typically provides pain relief 15 to 40 minutes after stimulation. Relief seems to be related to the release of endorphins and a susceptibility to hypnosis [12]. The efficacy of acupuncture for relieving pain has not been proven, as study samples have been small. However, acupuncture has been found to be of some benefit for cancer-related pain when the therapy is given in conjunction with analgesic therapy [66]. Other nonpharmacologic interventions that have been help- ful for some patients but lack a strong evidence base include manipulative and body-based methods (such as application of cold or heat, and positioning), yoga, distraction, and music or art therapy.
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MDNJ1525
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