Analgesics in palliative care

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:(1)

Step 1 (pain <3/10). Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs).

Pain persisting or increasing? If so go to:

Step 2 (pain 3-6/10). Weak opioid for mild-to-moderate pain + paracetamol and NSAIDs +/- adjuvant analgesic.

Pain persisting or increasing? If so go to:

Step 3 (pain >6/10). Strong opioid for moderate-to-severe pain + paracetamol and NSAIDs +/- adjuvant analgesic.

Objective: freedom from pain.

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 (2).

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:

1. WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain In Adults and Adolescents, 2018.
2. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control.