Pain & Symptom Management

Pain

Pain is one of the most common symptoms in palliative care. Pain can also be a much feared symptom which can contribute to its intensity. The aim of palliative care is to allow patients to be pain free or, for their pain to be sufficiently controlled so that it does not interfere with their ability to function or detract from their quality of life.

Good pain control requires:

accurate and detailed assessment, and reassessment, of each pain
knowledge of the different types of pains
a different therapeutic approach to chronic pain
knowledge of which treatment modalities to use
knowledge of the actions, adverse effects and pharmacology of analgesics
multidisciplinary assessment and treatment of other aspects of suffering that may aggravate pain – physical, psychological, social, cultural and spiritual distress.

The array of pain management options can be overwhelming and more information is available Medications and Symptom management . The Pain and Pain Management leaflet may be a useful resource to give to patients when discussing pain.

For patients with pain that is difficult to control contact the palliative care service in your region.

Medications

The use of medication for the treatment of acute pain is the same as for non-palliative care patients. The treatment of chronic pain, that is often poorly managed, requires a different approach to acute pain.

In palliative care:

the analgesic program should be kept simple, even for patients in severe pain
oral medication is the mainstay of treatment and should only be abandoned if the patient is unable to take or retain oral preparations.

There is a myriad of pain medications available as they treat different types of pain. To access up to date, evidence-based sources of advice on the appropriate use of analgesics and other treatments in palliative care refer to Medications and Symptom management .

For access to an opioid conversation chart refer to Eastern Metropolitan Region Palliative Care Consortium

Barriers to optimal pain control

Given explanation and reassurance, a well titrated morphine regime and the cover of antiemetics and aperients, most patients can use morphine without ill effect.

The following information is offered to deal with some of the misinformation and fear that exists about the use and effects of opiates.

Professional fears about opioid analgesia

Some reasons why doctors under-prescribe and nurses under-administer opioid drugs follow in bold type. These reasons are challenged by the points appearing beneath them.

A belief that morphine hastens death

morphine may be used for months or years and, correctly administered, is compatible with a normal lifestyle
used properly, it does not hasten death

The fear of respiratory depression

used properly, morphine should not cause respiratory depression, although care must be taken with patients who are at risk of respiratory depression for other reasons

A belief that “Morphine doesn’t work”

Morphine will be ineffective in controlling pain if

it is incorrectly administered
it is used for morphine-insensitive pain
matters of psychosocial concern have not been addressed

The belief that morphine causes unacceptable side effects

side effects should not be severe
respiratory depression is uncommon, except in opioid naive patients commenced on parenteral therapy
constipation occurs inevitably and requires explanation and advice about diet and laxative therapy
somnolence and nausea usually improve after several days

A fear of tolerance, physical dependence, psychological dependence

concerns about these are never a reason to delay treatment with an opioid if it is clinically indicated.

Patient fears about opioid analgesia

Patient education and participation in pain management is vital. Correction of misconceptions about pain management and opioid use is often necessary to achieve optimal use of analgesia.

Some of the concerns put forward by patients and their families follow in bold type. These concerns need to be addressed, and suggestions are given as to education and reassurance that can be given.

“That means I’m going to die soon”

requires explanation that morphine can be used for months or years and is entirely compatible with a normal lifestyle

“Nothing left for when the pain gets worse”

requires reassurance that the therapeutic range of morphine is sufficient to allow escalation of the dose if necessary

“I’ll become an addict”

requires explanation and reassurance about physical and psychological dependence

“The morphine didn’t work”

Morphine may not relieve pain if

the dose was too low
it was given too infrequently
there were no instructions for breakthrough pain
it was given for copied-insensitive pain
matters of psychosocial concern have not been addressed

“I couldn’t take the morphine”

unacceptable side effects should not occur
patients should be warned about somnolence and nausea and reassured that they are likely to improve after several days
constipation occurs inevitably and requires explanation and advice about diet and laxative therapy.

“I’m allergic to morphine”

usually relates to nausea or vomiting that occurred when parenteral morphine was given to an opioid patient for acute pain
immunological allergy to morphine is rare

Symptom management

Symptom management in palliative care requires skilled comprehensive assessment and attention to the whole person. Strategies to improve symptoms should be based on what the patient says is most distressing and should also be designed around the patients psychological, spiritual, emotional, cultural and social needs. Wherever possible, the patient should be the main source of information as to his/her needs for symptom control.

Palliative care practice is evolving rapidly. Resources offering up to date, evidence-based sources of advice can be found under:

or contact the palliative care service in your region for symptom management advice