Palliative Care and Pain Management at the End of Life ___________________________________________
switching has been established ( Figure 8 ); the first step is to calculate the equianalgesic dose of the new drug ( Table 9 ) [187; 206; 223]. Additional care is needed when switching to metha- done, and conversion ratios have been established ( Table 10 ) [187]. Evidence suggests that the traditionally recommended equianalgesic doses for the fentanyl transdermal patch are subtherapeutic for patients with chronic cancer-related pain, and more aggressive approaches may be warranted ( Table 11 ) [187; 223; 262]. 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 14, 2024.) Level of Evidence : Expert Opinion/Consensus Statement Another approach that has been used for pain management in the cancer setting is combination opioid therapy, or the concurrent use of two strong opioids. The effectiveness of this approach has been evaluated in only two studies, and the combination was morphine and oxycodone or morphine with fentanyl or methadone [263]. The evidence to support a recommendation of combination opioid therapy is weak, and the side effects most likely outweigh the benefit [263]. Opioids are associated with many side effects, the most notable of which is constipation, occurring in nearly 100% of patients. The universality of this side effect mandates that once extended treatment with an opioid begins, prophylactic treatment with laxatives must also be initiated. 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 [223]. Opioid rotation may also be done to reduce adverse events. 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 [67]. 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 [67]. 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 12 ) [187; 223]. 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 [264]. 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 [47; 265; 266]. Bone metas- tases are the most frequent cause of cancer-related pain; 50% to 75% of patients with bone metastases will have pain and impaired mobility [265]. 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 [265]. It takes one to four weeks for optimal therapeutic results [265; 266]. 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 [77; 78; 79]. As previously noted, reimburse- ment issues present a primary barrier to the use of palliative radiotherapy [77; 78; 79]. 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 [77; 78; 266; 267]. One study found that more than half (54%) of people use complementary/alternative medicine therapies at the end of life [268]. The most commonly used therapies are massage, music, relaxation techniques, and acupuncture [268; 269; 270; 271; 272].
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MDCA1525
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