pain associated with stretching of the liver capsule due to metastases, for treating bone pain (due to their anti- inflammatory effects) as well as for relieving malignant intestinal obstruction. 61 Dexamethasone produces the least amount of mineralocorticoid effect and is available in a variety of delivery forms, including oral, intravenous, subcutaneous, and epidural. 41 Local anesthetics may be useful in preventing procedural pain and in relieving neuropathic pain. Local anesthetics can be given topically, intravenously, subcutaneously, or intraspinally. Both gel and patch versions of lidocaine have been shown to reduce the pain of postherpetic neuralgia and cancer-related neuropathic pain. 62 Intravenous or subcutaneous lidocaine at 1 to 5 mg/ kg administered over 1 hour, followed by a continuous infusion of 1 to 2 mg/kg/hour, has been reported to reduce intractable neuropathic pain in patients in inpatient palliative care and home hospice settings. 63 NMDA antagonists (dextromethorphan, amantadine, and ketamine) are believed to exert their analgesic effects by blocking receptors for glutamate and other excitatory amino acids at the level of the spinal cord. Ketamine is the most commonly-used agent, and can be administered intravenously, intramuscularly, subcutaneously, intranasally, sublingually, rectally, and topically. A general recommendation is to reduce the opioid dose by approximately 25% to 50% when starting ketamine to avoid sedation. 41 Psychotomimetic reactions consisting of hallucinations, vivid imagery delirium, confusion, and irrational behavior have been reported to occur in approximately 12% of individuals receiving the drug systemically. 42 Adverse effects, including hallucinations and unpleasant cognitive sensations, responded to diazepam at a dose of 1 mg intravenously. 42 In recent years there has been a resurgence of interest in the use of cannabinoids for the relief of Complementary/alternative strategies A wide range of complementary and alternative therapies (CAT) are commonly used in end-of-life care. 69 More than half of providers that offered CAT offered massage, supportive group therapy, music
pain and the end of life. Like opioids, cannabinoids produce their pharmacological effects via actions at specific receptors in the body that are designed for endogenously produced compounds with normal regulatory, homeostatic properties. 64 Unlike opioids, however, there has never been a documented case of death from cannabis overdose—indeed, cannabis has no known lethal dose. 65 The CB1 and CB2 receptors have been shown to mediate the analgesic effects of cannabinoids. 66 This has allowed for the development of more selective agents that may provide analgesia while minimizing cognitive or perceptual side effects. Two oral cannabinoid preparations are FDA-approved and available in the US (dronabinol and nabilone). These routes of administration avoid the potential hazards and dosing uncertainties involved with inhaled or edible forms of cannabis. A review of the existing literature evaluating the role of cannabinoids currently approved for human use suggests that these agents are moderately effective for neuropathic pain with adverse effects that are less than or comparable to existing analgesics. 67 Cannabinoids have been shown to exert no appreciable effects on opioid plasma levels and may even augment the efficacy of oxycodone and morphine in patients suffering from a variety of chronic pain conditions, potentially allowing a reduction in the opioid doses used in such patients. 68 The authors of a review of the role of cannabinoids in hospice and palliative care concluded: “Many patients in a palliative care setting who are currently on long-term opioids for chronic pain could potentially be treated with either cannabis alone or in combination with a lower dose of opioids. From a pharmacological perspective, cannabinoids are considerably safer than opioids and have broad applicability in palliative care.” 64
and pet therapy, guided imagery, and relaxation techniques. 70 Behaviors likely to respond to CAT interventions include: aggression, disruption, shadowing, depression, and repetitive behaviors (Table 7).
Table 7. Potentially helpful alternative interventions for EOL symptoms 72
Intervention
Applications/indications
Environmental modifications 73,74
Support normal sleep/wake cycles Structure activities to reduce boredom
Reduce unnecessary stimulation Create home-like environment
Music therapy 75
Receptive music therapy (listening to music by a therapist who sings or selects recorded music for the recipients). Active music therapy (recipients engage in music-making by playing small instruments, with possible encouragement to improvise with instruments, voice, or dance.) Also music played when doing routine daily care etc. Exposure to simulated or natural lighting to promote circadian rhythm synchronization.
Bright light therapy 76
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Book Code: CA23CME
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