____________________________________________ 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
The application of cold and heat are particularly useful for localized pain and have been found to be effective for cancer- related pain caused by bone metastases or nerve involvement, as well as for prevention of breakthrough incident pain [12]. Alternating application of heat and cold can be soothing for some patients, and it is often combined with other nonphar- macologic interventions. Cold can be applied through wraps, gel packs, ice bags, and menthol. It provides relief for pain related to skeletal muscle spasms induced by nerve injury and inflamed joints. Cold application should not be used for patients with peripheral vascular disease. Heat can be applied as dry (heating pad) or moist (hot wrap, tub of water) and should be applied for no more than 20 minutes at a time, to avoid burning the skin. Heat should not be applied to areas of decreased sensation or with inadequate vascular supply, or for patients with bleeding disorders. Changing the patient’s position in the bed or chair may help relieve pain and also helps minimize complications such as decubitus ulcers, contractures, and frozen joints. Members of the healthcare team as well as family members and other informal caregivers can help reposition the patient for comfort and also perform range-of-motion exercises. Physical and occu- pational therapists can recommend materials, such as cushions, pillows, mattresses, splints, or support devices. Hatha yoga is the branch of yoga most often used in the medi- cal context, and it has been shown to provide pain relief for patients who have osteoarthritis and carpal tunnel syndrome but it has not been studied in patients at the end of life. Yoga
may help relieve pain indirectly in some patients through its effects on reducing anxiety, increasing strength and flexibility, and enhancing breathing [67]. Yoga also helps patients feel a sense of control. Methods to provide distraction from pain come in a wide variety of methods, including reciting poetry, meditating with a calm phrase, watching television or movies, playing cards, visiting with friends, or participating in crafts. Music therapy and art therapy are also becoming more widely used as nonpharmacologic options for pain management. Listening to music has been shown to decrease the intensity of pain and reduce the amount of opioids needed, but the magnitude of the benefit was small [68]. Research suggests that art therapy contributes to a patient’s sense of well-being [69]. Creating art helps patients and families to explore thoughts and fears during the end of life. An art therapist can help the creators reflect on the implications of the art work. Art therapy is especially helpful for patients who have difficulty expressing feelings with words, for physical or emotional reasons.
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MDNJ1525
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