All principles of pain management could be included as palliative care as it addresses managing symptoms to improve function and quality of life. From the perspective of palliative care and its focus on quality of life, moderate to severe pain is considered an emergency. Pain is one of patients’ greatest fears at the end of life and unrelieved pain is common among patients with nearly all serious illnesses, including cancer, chronic lung disease, and chronic heart disease.
Clinical Challenges
Pain management in palliative care must distinguish between chronic, non-malignant pain and pain due to progressive and life-limiting illness, such as advanced cancer, as the natural history of pain and the burden of longer-term side effects or complications may be quite different.
In palliative care, the goal of pain management centrally includes maximizing function, but additionally, patients’ goals for relief to a certain level are key (i.e. improving the pain score to a level acceptable to the patient).
Treatment Recommendations
- For severe, constant, ongoing pain, the most effective pharmacological treatment is often the combination of a long-acting opioid given around-the-clock and a short-acting formulation to be used as need for “breakthrough pain.”
- Buprenorphine is an opioid analgesic well-suited to palliative care as it has a lower risk of respiratory depression and tends to cause less constipation.
- As a significant cause of suffering as well as opioid non-adherence, opioid-induced constipation must be prevented and treated, typically with a stimulant laxative (such as senna) and an osmotic laxative, such as polyethylene glycol. Peripherally acting mu-opioid receptor antagonists (PAMORAs) should be used if simple stimulant laxative are ineffective.
- For neuropathic pain, a combination of neuropathic medication (such as gabapentin) and an opioid tends to be more effective than higher doses of a single agent.
- For particular causes of pain in palliative care, aggressive pain management techniques may be indicated, including radiation treatment, surgery, chemotherapy, and interventional pain techniques (including injections [eg. nerve blocks], implantable analgesic pumps, spinal cord stimulators). Additionally, integrative techniques may be particularly effective with minimal side effects, such as physical therapy, acupuncture, massage, Reiki, and medical cannabis.
- Ketamine (nasal or oral administration in the outpatient setting, IV or IM in the inpatient setting) is an analgesic medication that shows great promise for more routine use in palliative pain scenarios.
Special Considerations
When patients are at the end of life, the law of secondary effect is considered ethically acceptable. That is, a known but unintended complication of a pain medication treatment (e.g. respiratory suppression) is ethically valid in pursuit of an acceptable goal (e.g. adequate pain relief) based on patient wishes and autonomy.
In palliative care, powerful analgesics such as morphine and methadone are often necessary but face stigma from patients, families, and clinicians. The risk of opioid use disorder is important to screen for and address if present.
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