Concise Review for CliniciansUse of Opioids in the Treatment of Severe Pain in Terminally Ill Patients—Dying Should Not Be Painful
Section snippets
Illustrative Case
Mr C is a 54-year-old man who presents to the emergency department with severe abdominal pain of several days' duration. Computed tomography of the abdomen reveals a 5-cm mass in the head of the pancreas and the presence of hepatic metastases. The patient is in severe pain (rated a score of 9 on a scale of 0 to 10 in which 10 is the worst pain imaginable) (Table 1) and has been taking only over-the-counter analgesics, which are not relieving his pain.
Initiation of Analgesia
Although there is no tissue confirmation, there is a strong suspicion that this patient has metastatic pancreatic cancer, an ultimately terminal disease. Regardless of the diagnosis, he is in severe pain and requires strong medication for relief. Analgesia should not be delayed while the evaluation is being pursued. Immediate management calls for use of a strong opioid. Although many strong opioids are available, morphine is the prototypic drug, and no other drug is more effective for pain
Conversion to Oral Therapy
When converting from intravenous to oral morphine, the intravenous morphine must be discontinued at some time. Given the kinetics of the sustained-release preparations of opioids, it typically takes 4 to 6 hours to achieve adequate blood levels and up to 3 half-lives to achieve steady-state levels. The current recommendation is to stop the continuous intravenous infusion approximately 4 to 6 hours after the first oral dose of continuous-release medication, keeping the as-needed bolus doses
Routes of Drug Administration
Fortunately, multiple routes of administration are available for opioids, including oral, rectal, transdermal, intravenous, subcutaneous, epidural, intrathecal, and intramuscular. Because of erratic absorption and pain, the intramuscular route is generally discouraged. The epidural or intrathecal route requires placement of a catheter, and, although this approach can be effective for pain management, catheters are typically used only in special circumstances. Intravenous opioid administration
Treatment of Breakthrough Pain
The strategy for treatment of breakthrough pain should be determined. Because the patient is having difficulty taking oral medication, the parenteral routes, intravenous and subcutaneous, can be used. However, a more convenient approach is to use an oral high-concentration morphine solution such as Roxanal, which contains 20 mg of morphine per milliliter. One or 2 milliliters of the solution can be placed between the patient's cheek and gum. A rapid “burst” is absorbed by the buccal mucosa,
Reassessment of Opioid Dose
The patient's opioid requirements have decreased because of the nerve block. Therefore, his pain has decreased considerably, and his opioid requirements have decreased. The previous doses of opioids that he had tolerated now represent excessive doses, and adverse effects emerge. When a procedure is performed that may diminish the source of pain, the opioid requirements must be reassessed and readjusted.
Mr C's opioid dose is decreased by half and re-titrated to a level that produces pain control
Bowel Management
When use of narcotics is initiated in a patient, regardless of the route used, a bowel regimen should be initiated. Constipation is almost universal in patients taking opioids; prevention is more effective than treatment. A thorough history and physical examination should always be the cornerstone of the evaluation of any patient with pain. When pain recurs or is exacerbated, treatment and evaluation should be based on a thorough history and physical examination, and other potential confounding
Conclusion
Dying does not need to be painful. An appropriate evaluation to determine the etiology of the pain, followed by a rationally designed treatment plan coupled with appropriate analgesic dosing, can control the vast majority of pain in the dying patient.
Questions About Treating Severe Pain in Dying Patients
- 1.
Which one of the following routes of administration of analgesics should be avoidedin a patient who is unable to take oral medications?
- a.
Transdermal
- b.
Intramuscular
- c.
Subcutaneous
- d.
Buccal
- e.
Intravenous
- a.
- 2.
Which oneof the following is trueregarding administration of analgesia in a patient who presents with severe pain?
- a.
Should not be administered until a final pathologic diagnosis has been established
- b.
Should be administered only to patients who request it
- c.
Should be given immediately while the
- a.
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Cited by (7)
Medical interventions at the end of life: What is appropriate and who is responsible?
2005, Mayo Clinic ProceedingsChronic pain syndromes
2014, Harwood-Nuss' Clinical Practice of Emergency Medicine: Sixth EditionPalliative care intervention for choice and use of opioids in the last hours of life
2008, Journals of Gerontology - Series A Biological Sciences and Medical SciencesCommon myths about caring for patients with terminal illness: Opportunities to improve care in the hospital setting
2007, Journal of Hospital MedicineUnrestricted opiate administration for pain and suffering at the end of life: Knowledge and attitudes as barriers to care
2006, Journal of Palliative Medicine
A question-and-answer section appears at the end of this article.