analgesics in palliative care

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This section covers:

drugs used in palliative care to relieve pain

management of some specific types of pain encountered in palliative care
- consider three main types of cancer related pain:
  - visceral/soft tissue pain
    - • opioid sensitive - use the "ladder"
  - bone pain
    - NSAID sensitive
    - partly opioid sensitive
    - radiotherapy may help
  - nerve related
    - partly opioid sensitive
    - adjuvant analgesics may often be needed
  - also consider incident pain
    - exacerbations of pain on movement, may require fast acting analgesia

use of syringe drivers and how to set them up in the patient's home

The concept of the pain relief 'ladder' is one that is used in palliative care:

Step 3 - strong opioid e.g. morphine +/- non-opioid

Step 2 - weak opioid e.g. codeine +/- non opioid

Step 1 - Non opioid e.g. paracetamol, NSAID

The steps of the pain ladder are traversed 1 to 3 and the decision to go to the next step is based on whether pain persists or increases whilst at a particular step.

The ladder has no "top rung" as there is no maximum dose for strong opioids. If pain is still a problem with high doses of strong opioid (>300mg morphine equivalent/24 hours) or severe side effects, reconsider the cause of the pain - for example, bone pain may be better helped by NSAIDs - or seek specialist advice (1).

Notes:

many pains are not cancer related but may be:
- treatment related e.g. constipation, post radiotherapy
- coincident illness or condition e.g. arthritis, migraine. Many factors influence the perception of pain. e.g. fear, loneliness, boredom

Reference:

West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control.
St Elizabeth Hospice Guidelines, Ipswich, 1997

Last edited 08/2020

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