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Chapter 7: Palliative Pain Management

Introduction

Learning objectives for this chapter

By the end of this chapter, we would like you:

- To define the concept of 'pain'.

- To describe the symptoms associated with pain.

- To explain the pathophysiology of pain in terms of nociception.

- To discuss the types of pain, including their characteristics and effective analgesia options.

- To describe a broad range of pharmacological, non-pharmacological and combination interventions for pain management in the palliative care setting.

- To explain the prescription of analgesics using the World Health Organisation's Analgesic Ladder.

- To discuss the considerations and complications associated with the use of opioid analgesics.

- To describe the effective management of a 'pain crisis' in the palliative setting.

- To discuss the considerations and complications associated with palliative sedation.

Pain in the palliative care setting

Pain is highly subjective experience. Pain has a variety of complex negative physical, psychological, social and spiritual impacts:

Physical Impacts of Pain

Psychological Impacts of Pain

  • Impaired mobility.
  • Nausea.
  • Weakness, drowsiness.
  • Depression, anxiety,
  • Fear.
  • Anger, despair, hopelessness.

Social Impacts of Pain

Spiritual Impacts of Pain

  • Inability to work.
  • Restricted social activity.
  • Changes to role and function.
  • Loss of sense of purpose.
  • Change to expected life journey.
  • Feelings of being 'punished'.

Up to 70% of patients receiving palliative care report pain. Patients who experience the worst pain tend to: (1) be younger, (2) be in poorer general condition, and (3) have a shorter survival. Pain can significantly decrease quality and length of life.

The pathophysiology and types of pain

The process of pain is called nociception. Receptor cells called nociceptors detect noxious, or pain-causing, stimuli. These nociceptors transmit the stimuli as an electrical impulse to the brain.

There are many different types of pain; (1) nociceptive pain, and (2) neuropathic pain. Both types of pain may be: (1) constant, or (2) episodic. Different types of pain are treated using different types of analgesic medication:

Type of Pain

Character-istics

Example

Analgesic Medication

Nociceptive somatic

Constant

Bone metastasis

  • Opioids (partial)
  • Non-steroidal anti-inflammatories
  • Paracetamol, acetaminophen
  • Bisphosphonates
  • Topical anti-inflammatories
  • Tricyclic agents

Nociceptive somatic

Episodic

Pathological fracture, vertebral collapse

  • Opioids (partial)
  • Nerve block

Nociceptive visceral

Constant

Liver capsular pain

  • Opioids (partial)
  • Corticosteroids

Nociceptive visceral

Episodic

Tumour obstructing bowel

  • Opioids (partial)
  • Anticholinergics

Neuropathic

Constant

Chemotherapy-induced painful neuropathy

  • Opioids (partial)
  • Tricyclic agents
  • Antiepileptic agents

Neuropathic

Episodic

Brachial plexopathy

  • Tricyclic agents
  • Antiepileptic agents
  • Benzodiazepines

Pain may also be classified as either: (1) acute, or (2) chronic:

Acute Pain

Chronic Pain

Onset and Duration

  • Generally sudden onset.
  • Shorter-term duration.
  • Gradual or sudden onset.
  • Longer-term duration.

Cause

  • A clearly-defined cause (e.g. vertebral collapse, fracture, obstruction, tumour, etc.).
  • Cause may not be known, or may be unclear.

Course

  • Pain resolves as cause is addressed.
  • Pain may not resolve; may cycle through periods of improvement / worsening.

Goals of Treatment

  • Pain control and eventual elimination.
  • Pain control to the greatest extent possible; enhance function and quality of life.

There are also the following types of pain:

  • Background pain: mild to moderate 'baseline' pain, which is a constant feature of a patient's condition.
  • Breakthrough pain: more severe 'transient' or 'episodic' pain, which may occur at various times. It may be described as:
  • Paroxysmal breakthrough pain, which is idiopathic.
  • Incident breakthrough pain, with a clearly-defined cause.
  • End-of-dose breakthrough pain, where analgesic medications in a patient's body reduce below therapeutic levels.

Assessment of pain in the palliative care setting

Assessment depends on the situation; for severe, acute pain, assessment should be rapid to enable rapid intervention. For less-severe or chronic pain, a more comprehensive pain assessment can improve longer-term pain management. Rapid pain assessment uses the 'OPQRST' mnemonic.

Patients may be unable to describe their pain, or even communicate that they are in pain. In this situation, objective indicators should be used - for example:

  • An unexplained rise in heart rate and / or blood pressure.
  • A change in demeanour.
  • Other subtle signs (eg. diaphoresis, pallor, etc.).

Management of pain in the palliative care setting

Nurses should speak with the patient, and family members / carers / significant others (where appropriate), and consult the advance care planning documentation. Various strategies should be discussed, and informed and collaborative decisions made.

There may be a number of goals to pain management in the palliative care setting:

  • Modifying the pain's cause.
  • Raising the patient's pain threshold, or modifying their perception of pain.
  • Modifying the patient's environment and supporting activities of daily living.
  • Interrupting the pain pathways.

Analgesics are the primary treatment. Analgesic medications may act by: (1) blocking receptors and preventing the transmission of electrical impulses along pain pathways, or (2) preventing the production of substances, such as the enzyme cyclooxygenase, which contribute to pain. There are three different types of analgesic medications commonly used in palliative care: 

Type of Analgesic Medication

Description

Examples

Non-opioids

Usually used for mild to moderate pain, or in combination with other medications for more severe pain.

  • Paracetamol.
  • Aspirin.
  • Non-steroidal anti-inflammatories.

Opioids

Usually used for moderate to severe pain; associated with a number of noteworthy side-effects.

  • Codeine.
  • Tramadol.
  • Morphine.
  • Oxycodone.
  • Fentanyl.

Adjuvants (also 'co-analgesics')

Usually used in combination with non-opioids and / or opioids, and / or for atypical pain.

  • Tricyclic agents.
  • Antiepileptic agents.
  • Corticosteroids.
  • Anticholinergics.
  • Benzodiazepines.

Anaesthetics, particularly local anaesthetics, are sometimes used, usually for severe intractable pain.

It can be complicated to decide on the best combination of pain medications to prescribe to a person receiving palliative care. The World Health Organisation has developed a tool known as the Analgesic Ladder:

Severe Pain

(unrelieved by previous step)

Moderate Pain

(unrelieved by previous step)

  • Strong opioid analgesic +/- non-opioid analgesic +/- an adjuvant analgesic.

Mild Pain

  • Mild opioid analgesic +/- non-opioid analgesic +/- an adjuvant analgesic.
  • Non-opioid analgesic +/- an adjuvant analgesic.

Medication may be administered in a variety of different ways - for example:

  • Enterally. Often just as effective as parenteral administration, though onset of action may be slower.
  • Parenterally. Quick-acting. May involve the use of patient-controlled syringe drivers.
  • Alternative routes (e.g. suppository, transdermal patch, etc.).

Analgesic medications may be:

  • Regularly prescribed (i.e. with a set dose taken at set times).
  • Administered as required (i.e. top-up doses taken for breakthrough pain).

Use of opioid medication in the palliative care setting

Opioids are divided into two categories:

Opioids for Mild-to-Moderate Pain

Opioids for Moderate-to-Severe Pain

  • Codeine
  • Dihydrocodeine
  • Tramadol
  • Buprenorphine
  • Morphine, diamorphine
  • Oxycodone
  • Fentanyl
  • Methadone

Opioids are associated with a range of significant side-effects:

  • Constipation: most patients are offered prophylactic oral aperients. Standard nursing care to prevent / treat constipation is also used.
  • Nausea and vomiting: anti-emetics may be prescribed. Complementary techniques may also be effective.
  • Sedation: can result at high doses. Usually decreases within a few days to a few weeks of commencement; however, reduction of dose (if feasible), an alternative opioid and / or use of a psychostimulant may be recommended.
  • Confusion and / or delirium: mild cognitive impairment is common immediately following commencement of an opioid analgesic. Symptoms are usually transient; if the confusion and / or delirium persists, alternative causes are investigated.
  • Multifocal myoclonus: involuntary twitches and jerks and, in more severe cases, seizures. Myoclonus can contribute significantly to patient's pain, and may indicate opioid toxicity. Usually, myoclonus requires dose reduction (if feasible), changing to an alternative opioid and / or use of a benzodiazepine to control symptoms.
  • Urinary retention: an uncommon but potentially significant side-effect. Older men with a pre-existing enlarged prostate are particularly at risk. Reduction of opioid dose (if feasible), changing to an alternative opioid and / or use of medications to stimulate urination may be used.
  • Pruritus: commonly associated with morphine, and less-commonly associated with fentanyl. Managed using standard pruritis care.
  • Respiratory depression: although rare, respiratory depression is the most significant complication, usually alongside other indicators of CNS depression such as sedation. Opioid-induced respiratory depression should not be confused with the changes in respiration which occur naturally at the end of life.

Important principles for use of opioid analgesics in palliative care:

  • Analgesics must be selected according to the WHO's Analgesic Ladder.
  • Use appropriate drug combinations to improve pain relief, where required.
  • Avoid drug combinations that increase risks without improving pain relief.
  • Consider the patient's age, metabolic state, organ function, coexisting disease, etc.
  • Consider accumulation of metabolites, effects of / interactions with concurrent drugs, etc.
  • Consider the available and preferred routes of administration.
  • Consider issues which may affect the patient's ability to follow the prescribed regimen.
  • Administer opioid analgesics regularly for persistent pain.
  • Consider 'rescue' (or 'as required') doses for breakthrough pain.
  • If opioid analgesics are discontinued, ensure they are tapered to avoid withdrawal.
  • Systematically and regularly evaluate the effectiveness of the analgesic regimen.
  • Provide the patient and their significant others with appropriate education.

Many patients fear and resist use of opioid analgesic medication. Nurses should educate patients about how these medications can be used safely and effectively. This involves correcting many misperceptions associated with opioid analgesics, such as:

Misperception

Fact

Opioids are addictive.

Opioid analgesic medications are very rarely addictive.

Tolerance to opioids develops, and progressively higher doses will be required.

A patient will rarely develop tolerance to opioids. As a person's disease progresses, they may require higher doses.

Opioids are a tool of euthanasia; once these are prescribed, end of life is near.

Euthanasia is illegal in the UK; opioids are never prescribed for euthanasia. Opioids will not cause death.

Allergies to opioids are common.

Side-effects of opioid analgesic medications (not allergies) are relatively common; however, these can be managed with appropriate interventions.

Non-pharmacological interventions for pain management

Nurses should consider complementary pain relief techniques to be used in combination with analgesic medications to potentially improve pain relief. Non-pharmacological interventions include:

  • Psychological interventions, including:
  • Psychoeducation, including the aetiology of pain, the principles and methods of pain relief, options for analgesia, side-effects, associated equipment and devices, and concepts such as dependence / tolerance / addition, etc.
  • Cognitive interventions. Distraction and guided imagery can both be effective. Coping self-statements or positive affirmations can also help a person to transition through a painful experience. Relaxation techniques can help reduce skeletal muscle tension and relieve pain. Hypnosis can be used by a patient to control negative thoughts related to pain.
  • Behavioural interventions. For example, a pain diary can help patients to identify triggers for and patterns in their pain experience.
  • Psychotherapeutic interventions. For example, cognitive behavioural therapy can be used to enhance a person's self-efficacy in relation to pain control.
  • Physical interventions, including:
  • Positioning and movement. Repositioning and gentle movement, within the limits of the patient's tolerance, can assist in relieving pain.
  • Supportive devices. Canes, walkers and wheelchairs can help to ease pain during movement.
  • Other physical interventions - the application of heat / cold, and the use of vibration, massage and ultrasound - may help relieve pain.
  • Neuro-stimulatory interventions, including:
  • Transcutaneous electrical nerve stimulation (TENS). This may help to disrupt the transmission of electrical impulses along pain pathways in the body.
  • Invasive interventions:
  • Neuro-blockades and neuro-destructive procedures, which respectively block and destroy the nerves in a small part of the body and so prevent transmission of 'pain signals'.
  • Integrative interventions:
  • Alternative medicine. For example, acupuncture, moxibustion and other Eastern therapies, may help to relieve pain.
  • Mind-body interventions. For example, music therapy can help to comfort a patient and decrease their experience of pain.
  • Manipulative and body-based methods. For example, energy therapies such as therapeutic touch (e.g. Reiki) can be beneficial for some patients.

Many complementary therapies lack supporting evidence. However, if they are unlikely to be harmful, and may convey some benefit (physical and / or psychological) to the patient, nurses should support patients in their use. Nurses should be familiar with the types of complementary therapy options available in their workplaces.

Managing a pain crisis

A pain crisis occurs when pain is severe, uncontrolled and very distressing for a patient. A pain crisis usually involves acute breakthrough pain; however, it may also involve chronic pain which increases gradually in severity. A pain crisis can have a serious negative impact on a person's quality of life, and it may also hasten their death; therefore, a pain crisis must be considered a medical emergency.

Managing a pain crisis usually involves titration of opioid analgesia until adequate pain control is achieved. In patients who do not respond to opioid titration, or who develop intolerable side-effects, there are alternatives:

  • A parenteral non-steroidal anti-inflammatory (e.g. ketorolac).
  • A parenteral steroid (e.g. dexamethasone).
  • An anaesthetic (e.g. lidocaine, ketamine - via a nerve block or spinal delivery).

Sedation at the end of life

Some patients will experience pain which cannot be controlled using the interventions described. Palliative sedation may be an option. Clear communication and documentation is essential. The interdisciplinary team must be familiar with the relevant legal and ethical issues associated with the use of palliative sedation, including:

  • The goals of the use of palliative sedation.
  • The patient's desire for resuscitation.

Palliative sedation is not euthanasia. Rather, the goal is to relieve a patient's intractable pain.

Conclusion

Pain is a common experience for almost all patients receiving palliative care. Nurses must understand how to manage this issue; however, pain in the palliative care setting, and its relief and control, can be complex. In this chapter, you have studied the pathophysiology of pain, the characteristics of the different types of pain, and their assessment in the palliative care setting. This chapter has also described different pharmacological and non-pharmacological strategies which may be used in palliative care settings, and relevant considerations associated with their use.


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