Palliative Care and Pain Management at the End of Life ___________________________________________
Management Strong evidence supports pain management approaches for people with cancer, but the evidence base for management of pain in people with other life-limiting diseases is weak [47; 54; 108; 187; 212; 214]. Effective pain management involves a multidimensional approach involving pharmacologic and nonpharmacologic interventions that are individualized to the patient’s specific situation [223]. Pharmacologic Interventions The WHO analgesic ladder, introduced in 1986 and dissemi- nated worldwide, remains recognized as a useful educational tool but not as a strict protocol for the treatment of pain. It is intended to be used only as a general guide to pain manage- ment [245]. The three-step analgesic ladder designates the type of analgesic agent based on the severity of pain ( Figure 6 ) [245]. Step 1 of the WHO ladder involves the use of nonopioid analgesics, with or without an adjuvant (co-analgesic) agent, for mild pain (pain that is rated 1 to 3 on a 10-point scale). Step 2 treatment, recommended for moderate pain (score of 4 to 6), calls for a weak opioid, which may be used in combination with a step 1 nonopioid analgesic for unrelieved pain. Step 3 treatment is reserved for severe pain (score of 7 to 10) or pain that persists after Step 2 treatment. Strong opioids are the opti- mum choice of drug at Step 3. At any step, nonopioids and/or adjuvant drugs may be helpful. Some consider this model to be outdated and/or simplistic, but most agree that it remains foundational. It can be modified or revised, as needed, to apply more accurately to different patient populations.
The WHO ladder is also accompanied by five guiding prin- ciples [245]: • Reduce pain to levels that allow an acceptable quality of life. • Global assessment of the patient should guide treat- ment, recognizing that individuals experience and express pain differently. • The safety of patients, carers, healthcare providers, communities, and society must be assured. • A pain management plan includes pharmacologic treat- ments and may include psychosocial and spiritual care. • Analgesics, including opioids, must be accessible: both available and affordable. The pharmacologic treatment of pain involves selecting the right drug(s) at the right dose, frequency, and route, and man- aging side effects [223]. A decision pathway was developed for use in the cancer setting and can be applied to other settings ( Figure 7 ) [223]. Nonopioid analgesics, such as aspirin, acetaminophen (Tyle- nol), and nonsteroidal anti-inflammatory drugs (NSAIDs), are primarily used for mild pain (Step 1 of the WHO ladder) and may also be helpful as co-analgesics at Steps 2 and 3. Acet- aminophen is among the safest of analgesic agents, but it has essentially no anti-inflammatory effect. Toxicity is a concern at high doses, and the maximum recommended dose is 3–4 g per day [223]. Acetaminophen should be avoided or given at lower doses in people with a history of alcohol abuse or renal or hepatic insufficiency [223].
THE WORLD HEALTH ORGANIZATION’S THREE-STEP LADDER OF ANALGESIA
Step 3 Strong opioids +/- Non-opioids +/- Adjuvant analgesics
Severe pain (7-10 on a 10-point scale)
Step 2 Weak opioids +/- Non-opioids +/- Adjuvant analgesics
Mild-to-moderate pain (4-6 on a 10-point scale)
Mild pain (1-3 on a 10-point scale)
Step 1 Non-opioids +/- Adjuvant analgesics
Source: [245]
Figure 6
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MDCA1525
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