Challenges in Pain Management at the End of Life

Imran Khan MD

Medical Director Nanotechnology Medical Center  Lahore

Effective pain management in the terminally ill patient requires an understanding of pain control strategies.

Pain control is one of the most challenging tasks that family  face when providing care for patients at the end of life. CIDPUSA has developed a pain control protocol which can be practiced at home by any family member.

 

Systemic local anesthetics may be useful in patients who cannot tolerate tricyclic antidepressants or cannot take those medications because of cardiac disease (Table 1). In patients with refractory pain, orally or transdermally administered clonidine (Catapres, Catapres-TTS) can be used as an adjuvant to opioid therapy.

Lancinating or Paroxysmal Pain. Anticonvulsants are first-line options for the treatment of lancinating or paroxysmal neuropathic pain¹(Table 1). Patients with trigeminal neuralgia have been shown to respond well to carbamazepine (Tegretol).Because carbamazepine has potential bone marrow side effects, other anticonvulsants are better options in patients with a history of bone marrow suppression.

Gabapentin (Neurontin) has advantages over other anticonvulsants because of its safety profile and lack of drug interactions. In addition, no monitoring of plasma concentration is required. Baclofen (Lioresal) can be used as a first-line drug in the treatment of lancinating or paroxysmal neuropathic pain. In patients with refractory pain, oral local anesthetics, tricyclic antidepressants, clonidine and topical capsaicin 0.025 percent (Zostrix) may be used.

TABLE 1 Adjuvant Therapy for Lancinating or Paroxysmal Neuropathic Pain Medication Starting dosage* Maximum per day* Carbamazepine (Tegretol)† 200 mg twice daily 1.6 g Clonazepam (Klonopin)‡ 0.5 mg three times daily 20 mg Divalproex (Depakote)‡ 10 mg per kg per day 60 mg per kg Gabapentin (Neurontin)§ 100 mg three times daily 3.6 g Lamotrigine (Lamictal)† 50 mg once daily 500 mg Phenytoin (Dilantin)‡ 100 mg three times daily 600 mg Baclofen (Lioresal)§ 5 mg three times daily 80 mg *--Reduce dosage in children and the elderly. †--Reduce dosage in patients with hepatic and/or renal impairment. ‡--Reduce dosage in patients with hepatic impairment. §--Reduce dosage in patients with renal impairment. Product information from Physicians' desk reference. 54th ed. Montvale, N.J.: Medical Economics, 2000.