__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
Higher opioid doses administered at shorter intervals may thus be necessary. Concomitant opioids can be given for pain to a patient prescribed buprenorphine, but typically hydromorphone or fentanyl may be the most effective due to competitive binding at the opioid receptor. Since extended-release naltrexone will block the effects of any opioid analgesics, acute pain in such patients (e.g., that associated with dental work, surgery, or traumatic injury) should be treated with regional analgesia, conscious sedation, nonopioid analgesics, or general anesthesia. PALLIATIVE CARE Palliative care is specialized medical care for people with serious illness. Palliative care involves three key areas: symptom management (e.g., pain, nausea, constipation), supporting patients and their loved ones as they cope with illness and death, and communication and education about the illness through advance care planning (ACP). In the past decade a more nuanced model of care has been introduced, which integrates palliative care with disease-modifying care across the duration of an illness and includes consideration of those affected by the death of the individual. Pain control is a central focus of palliative care, but the goal of pain management is not simply the elimination of all pain, it is the control of pain sufficient for a given patient to achieve their highest quality of life in the moment. In the palliative care setting, clinicians may need to manage acute pain (e.g., post-surgical or post-treatment pain) or chronic pain or both types of pain simultaneously. Clinicians can avail themselves of a wide range of pharmacologic and nonpharmacologic approaches for pain management, which should be employed using the following general principles: • Identify and treat the source of the pain, if possible, although pain treatment can begin before the source of the pain is determined. • Select the simplest approach first. This generally means using nonpharmacologic approaches as much as possible and/or trying medications with the least severe potential side effects and at the lowest effective doses. • Establish a function-based management plan if treatment is expected to be long-term. A range of nonpharmacological treatments may help patients manage chronic pain, which can be used alone or in combination with pharmacological treatments: • Physical therapy • Yoga • Acupuncture • Massage
• Transcutaneous electrical nerve stimulation • Cognitive behavioral therapy • Mindfulness meditation • Weight loss Medications used to treat chronic pain in palliative settings
include the following: • Acetaminophen • NSAIDs • Antidepressants • Anticonvulsants
• Topical lidocaine or capsaicin • Cannabinoid-based therapies • Opioids
MANAGING END-OF-LIFE PAIN Although pain relief is often considered—and may sometimes be—an end unto itself, pain management and control of symptoms at the end of life may be more appropriately viewed as means of achieving the more primary goal of improving or maintaining a patient’s overall quality of life. For some patients, mental alertness sufficient to allow maximal interactions with loved ones may be more important than physical comfort. Optimal pain management, in such cases, may mean lower doses of an analgesic and the experience by the patient of higher levels of pain. 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 United States 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.
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