Women's Health and Education Center (WHEC) - End-of-Life Care: Pain Assessment and Management

End-of-Life Care: Pain Assessment and Management

WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers.Educational grant provided by Women's Health and Education Center (WHEC).

The inadequate management of pain is the result of several factors related to both patients andclinicians. Education and open communication are the keys to overcoming these barriers. Everymember of the healthcare team should reinforce accurate information about pain management withpatients and families. The clinician should initiate conversations about pain management, especiallyregarding the use of opioids, as few patients will raise the issue themselves or even express theirconcerns unless they are specifically asked ⁽¹⁾. Encouraging patients to be honest about pain andother symptoms is also vital. Clinicians should ensure that patients understand that pain ismultidimensional and emphasize the importance of talking to a member of the healthcare team aboutpossible causes of pain, such as emotional or spiritual distress. The healthcare team and patientshould explore psychosocial and cultural factors that may affect self-reporting of pain, such asconcern about the cost of medication. The prevalence of pain at the end of life varies, with ranges of8% to 96% being reported ⁽²⁾. Because pain is frequently encountered in the palliative and hospicecare environments, and knowledge of appropriate diagnosis and alleviation is vital to all members ofthe interdisciplinary team.

The purpose of this End-of-Life Care Series is to provide an overview of the assessmentand management of pain in the end of life, focusing on the components integral to providing optimumcare. This review discusses the etiology of pain at the end of life and issues in effective painmanagement; assessment of pain accurately through use of clinical tools and other strategies,including the use of an interpreter; and select appropriate pharmacologic and/or non-pharmacologictherapies to manage pain in patients during the end-of-life period.

Issues in Effective Pain Management

Pain can be caused by a multitude of factors. For patients with cancer, the most common sourceof pain is the underlying lesion or disease process itself. In addition, pain is frequently exacerbated byother physical symptoms and by psychosocial factors, such as anxiety or depression ⁽³⁾. Culturaland demographic factors may also contribute to lack of effective pain management. Expression ofpain and the use of pain medication differ across cultures. For example, Hispanic and Filipinopatients have been shown to be reluctant to report pain because of fear of side effects or addiction⁽²⁾. Some studies have shown that black and Hispanic patients in cancer centers were less likely tohave effective analgesics prescribed ⁽⁴⁾. Even when effective opioids have been prescribed, accessmay be difficult, as inadequate supplies of opioids are more likely in pharmacies in primarily nonwhiteneighborhoods ⁽³⁾, ⁽⁴⁾. Communication with patients regarding level of pain is a vital aspect of caringfor patients in the end of life. When there is an obvious disconnect in the communication processbetween the practitioner and patient due to the patient’s lack of proficiency in the English language, aninterpreter is required. Patients’ attitudes that are barriers to effective pain relief include:

Fear of addiction to opioids;

Worry that if pain is treated early, there will be no options for treatment of future pain;

Anxiety about unpleasant side effects from pain medications;

Fear that increasing pain means that the disease is getting worse;

Desire to be a “good” patient;

Concern about the high cost of medications.

There are several other ways clinicians can allay patients’ fears about pain medication:

Assure patients that the availability of pain relievers cannot be exhausted; there will always be medications if pain becomes more severe;

Acknowledge that side effects may occur, but emphasize that they can be managed promptly and safely and that some side effects will abate over time;

Explain that pain and severity of disease are not necessarily related.

Encouraging patients to be honest about pain and other symptoms is also vital.

Pain Assessment

As the fifth vital sign, pain should be assessed as frequently as the other vital signs and thefindings should be well documented, for easy reference by all members of the healthcare team ⁽⁵⁾.Pain is a subjective experience, and as such, the patient’s self-report of pain is the most reliableindicator. Research has shown that pain is underestimated by healthcare professionals andoverestimated by family members ⁽⁵⁾. Therefore, it is essential to obtain a pain history directly fromthe patient, when possible, as a first step toward determining the cause of the pain and selectingappropriate treatment strategies. When the patient is unable to orally communicate, other strategiesmust be used to determine the characteristics of the pain, as will be discussed. Questions should beasked to elicit descriptions of the pain characteristics, including its location, distribution, quality,temporal aspect, and intensity. In addition, the patient should be asked about aggravating or alleviatingfactors. Pain is often felt in more than one area, and physicians should attempt to discern if the painis focal, multifocal, or generalized. Focal or multifocal pain usually indicates an underlying tissueinjury or lesion, whereas generalized pain could be associated with damage to the central nervoussystem. Pain can also be referred, usually an indicator of visceral pain.

The quality of the pain refers to the sensation experienced by the patient, and it often suggeststhe pathophysiology of the pain ⁽⁶⁾. Pain that is well localized and described as aching, throbbing,sharp, or pressure-like is most likely somatic nociceptive pain. This type of pain is usually related todamage to bones and soft tissues. Diffuse pain that is described as squeezing, cramping, orgnawing is usually visceral nociceptive pain. Pain that is described as burning, tingling, shooting, orshock-like is neuropathic pain, which is generally a result of a lesion affecting the nervous system.Temporal aspects of pain refer to its onset (acute, chronic, or “breakthrough”). A recent onsetcharacterizes acute pain, and there are accompanying signs of generalized hyperactivity of thesympathetic nervous system (diaphoresis and increased blood pressure and heart rate). Acute painusually has an identifiable, precipitating cause, and appropriate treatment with analgesic agents willrelieve the pain. When acute pain develops over several days with increasing intensity, it is said to besubacute. Episodic, or intermittent, pain occurs during defined periods of time, on a regular orirregular basis ⁽⁷⁾. Chronic pain is defined as pain that persists for at least three months beyond theusual course of an acute illness or injury. Such pain is not accompanied by overt pain behaviors(grimacing, moaning) or evidence of sympathetic hyperactivity. "Breakthrough" is the term used todescribe transitory exacerbations of severe pain over a baseline of moderate pain ⁽⁸⁾. Breakthroughpain can be incident pain or pain that is precipitated by a voluntary act (such as movement orcoughing), or can occur without a precipitating event. Often, breakthrough pain is a consequence ofinadequate pain management.

Documentation of pain intensity is the key, as several treatment decisions depend on the intensityof the pain. For example, severe, intense pain requires urgent relief, which affects the choice of drugand the route of administration. Many assessment tools have been developed, and among the morecommonly used tools are the Wisconsin Brief Pain Questionnaire, the Memorial Pain AssessmentCard, and the McGill Pain Questionnaire (short form) ⁽⁹⁾. Simpler forms of measuring pain includenumerical rankings (patients rate pain on a scale of 0 to 10), and visual analogue scales (patientsrate pain on a line from 0 to 10). Verbal rating scales, which enable the patient to describe the pain as"mild," "moderate," or "severe," have also been found to be effective. Some patients, however, mayhave difficulty rating pain using even the simple scales. In an unpublished study involving 11 adultswith cancer, the Wong-Baker FACES scale, developed for use in the pediatric setting, was found tobe the easiest to use among three pain assessment tools that include faces to assess pain ⁽⁷⁾.

Wong-Baker FACES Pain Scale Rating

0-10 Pain Scale; Mild, Moderate or Severe

Note: equivalence between these two scales is:

1. No pain observed or patient denies pain – 0 out of 10

2. Mild pain – 1 to 3 out of 10

3. Moderate pain – 4 to 7 out of 10

4. Severe pain – 8 to 10 out of 10

Functional assessment is important. The healthcare team should observe the patient to see howpain limits movements and should ask the patient or family how the pain interferes with normalactivities. Determining functional limitations can help enhance patient compliance in reporting painand adhering to pain-relieving measures, as clinicians can discuss compliance in terms of achievingestablished functional goals ⁽¹⁾. Physical examination can be valuable in determining an underlying cause of pain. Examination of painful areas can detect evidence of trauma, skin breakdown, orchanges in osseous structures. Auscultation can detect abnormal breath or bowel sounds;percussion can detect fluid accumulation; and palpation can reveal tenderness. A neurologicexamination should also be carried out to evaluate sensory and/or motor loss and changes inreflexes. During the examination, the clinician should watch closely for nonverbal cues that suggestpain, such as moaning, grimacing, and protective movements. These cues are especially important when examining patients who are unable to verbally communicate about pain.

Pain Assessment in Non-Verbal Patient/Advanced Dementia Scale

	0	1	2	Score
Breathing Independent of Vocalization	Normal	Occasional labored breathing. Short period of hyperventilation.	Noisy labored breathing. Long period of hyperventilation. Cheyne-strokes respirations.
Negative Vocalization	None	Occasional moan or groan. Low level of speech with a negative or disapproving quality.	Repeated troubled calling out. Loud moaning or groaning. Crying.
Facial Expression	Smiling, or Inexpressive.	Sad. Frightened. Frown.	Facial grimacing.
Body Language	Relaxed.	Tense. Distressed pacing. Fidgeting.	Rigid. Fists clenched, knees pulled up. Pulling or pushing away. Striking out.
Consolability	No need to console.	Distracted or Reassured by voice or touch.	Unable to console, distract or reassure.
Document Intervention		Total,

Key: 0-10 scale. Anything >4 requires medication for comfort

Pain Management

There is no evidence to support specific pain management interventions for patients with somelife-limiting diseases, such as heart failure or dementia ⁽¹⁰⁾. There is, however, strong evidence tosupport approaches to treat cancer pain; namely, non-steroidal anti-inflammatory drugs (NSAIDs),opioids, and radiotherapy ⁽¹⁰⁾. Bisphosphonates have been effective for bone pain ⁽¹⁰⁾.

The overall objectives of pharmacologic management of pain include ⁽¹¹⁾:

Selection of the appropriate drug, dose, route, and interval;

Aggressive titration of the drug dose;

Prevention of pain and relief of breakthrough pain;

Use of appropriate co-analgesic medications;

Prevention and management of side effects.

Achieving the first four of these objectives is best done with use of the World Health Organization(WHO) three-step analgesic ladder, which designates the type of analgesic agent based on theseverity of pain ⁽¹²⁾. Step 1 of the WHO ladder involves the use of non-opioid analgesics, with orwithout an adjuvant (co-analgesic) agent, for mild pain (pain that is rated 1 to 3 on a 10-point scale).Step 2 treatment, recommended for moderate pain (score of 4 to 6), calls for a low dose of an opioid,which may be used in combination with a step 1 non-opioid analgesic for unrelieved pain. Step 3treatment is reserved for severe pain (score of 7 to 10) or pain that persists after Step 2 treatment.Opioids are the optimum choice of drug at Step 3, often in higher doses than at Step 2. At any step,non-opioids and/or adjuvant drugs may be helpful. Before describing the various non-opioid andopioid analgesic agents, two important principles must be noted. First, treatment according to theWHO analgesic ladder should correspond with the intensity of pain as described by the patient,regardless of whether treatment at a previous step was carried out. For example, if a patient hassevere pain when initially assessed, treatment should begin at Step 3, not Step 1. Second,analgesics must be administered on around-the-clock dosing, not on an as-needed basis. Not only isthis approach more effective at controlling pain but it also avoids unnecessary pain as a prompt forthe next dose.

Non-opioid analgesics include aspirin, acetaminophen, and NSAIDs. They are primarily used formild pain (Step 1 of the WHO ladder) and may also be helpful as co-analgesics at Steps 2 and 3.Acetaminophen is among the safest of analgesic agents, but it has essentially no anti-inflammatory effect. When given at high doses (4,000 mg per day), the drug can cause liver dysfunction; therefore,it should be avoided or used at lower doses for patients who have renal insufficiency or liver failure⁽¹³⁾. NSAIDs are most effective for pain associated with inflammation. Among the commonly usedNSAIDs are ibuprofen, naproxen, and indomethacin. There are several classes of NSAIDs, and theresponse differs among patients; trials of drugs for an individual patient may be necessary todetermine which drug is most effective ⁽⁹⁾, ⁽¹⁵⁾. NSAIDs inhibit platelet aggregation, increasing the riskof bleeding, and also can damage the mucosal lining of the stomach, leading to gastrointestinalbleeding ⁽³⁸⁾. There is a ceiling effect to the non-opioid analgesics; that is, there is a dose beyondwhich there is no further analgesic effect. In addition, many side effects of non-opioids can be severeand may limit their use or dosing.

Management of Pain in Adults According To the World Health Organization (WHO) Ladder

Drug	Typical Starting Dose and Route^a	Onset of Action	Duration of Action (Hours)
WHO Step 1: Mild Pain (score of 1-3 on a 10-point scale)
Aspirin	650 mg PO	30 min	3-4
Acetaminophen	650 mg PO	15 to 30 min	3-4
NSAIDs Ibuprofen Naproxen Indomethacin Piroxicam	200-800 mg PO 250-275 mg PO 25-75 mg PO 10-20 mg PO	30 min 60 min 30 min to several hrs Several hrs	4-6 6-12 4-12 24
Step 2: Moderate Pain (score of 4-6 on a 10-point scale)
Acetaminophen combinations
Plus codeine Plus oxycodone Plus hydrocodone	60 mg PO 5-10 mg PO 10 mg PO	30 min Unknown 30 to 60 min	3-4 3-4 4-6
Codeine	30-60 mg PO 30 mg IV/SC	30 to 45 min	4-6
Hydrocodone	10-30 mg PO	30 to 60 min	4-8
Morhpine^b (immediate release)	5-15 mg PO 2-10 mg/hr IV 4-15 mg SC	30 min 10-30 min 10-15 min	3-4 3-4 3-4
Step 3: Severe Pain (score of >7 on a 10-point scale)
Morphine (sustained release)	15-30 mg PO	60 min	8-12
Oxycodone (immediate release)	5-10 mg PO	10 to 15 min	3-6
Oxycodone (sustained release)	10-20 mg PO	30 min	12
Hydromorphone	2-4 mg PO 0.3-1.5 mg IV	15 to 30 min	4-6 2-4
Methadone	5-10 mg PO 2.5-10 mg IV	30 to 60 min	4-8
Levorphanol	2-4 mg PO	10 to 60 min	6-8
Fentanyl	50-100 mcg IV Transdermal patch (25 mcg/hr)	5-10 min 12 to 24 hr	Varies 48-72
^a Doses given are guidelines for opioid-naïve patients; actual doses should be determined on an individual basis. ^b Also used in Step 3. NSAIDs: non-steroidal anti-inflammatory drugs; IV: intravenous; SC: subcutaneous; PO: per oral route.

Moderate pain (Step 2) can be treated with analgesic agents that are combinations ofacetaminophen and an opioid, such as codeine, oxycodone, or hydrocodone. Strong opioids are usedfor severe pain (Step 3). There is no conclusive evidence of the superiority of one opioid over another⁽¹⁶⁾. Morphine, oxycodone, hydromorphone, and fentanyl are the most widely used opioids in theUnited States ⁽¹⁷⁾. Morphine is the most commonly used opioid for Step 3, and its efficacy has beenestablished ⁽¹⁷⁾. Morphine is available in both immediate-release and sustained-release forms, andthe latter form can enhance patient compliance. The sustained-release tablets should not be cut,crushed, or chewed, as this counteracts the sustained-release properties. The sustained-releaseform of oxycodone (OxyContin) has been shown to be as safe and effective as morphine for cancer-related pain, and it may be associated with less common side effects, especially hallucinations anddelirium ⁽¹⁷⁾. Oxycodone is also available in an immediate-release form (Roxicodone).Hydromorphone and fentanyl are the most potent opioids; neither drug should be given to an opioid-naïve patient. Hydromorphone, which is four times as potent as morphine, is available in immediate-release form. An extended-release form of hydromorphone was approved by the FDA in 2004;however, sales and marketing of the drug were suspended by the manufacturer in 2005 because ofthe potential for severe side effects when taken with alcohol ⁽¹⁸⁾. Fentanyl is the strongest opioid(approximately 80 times the potency of morphine) and is available as a transdermal drug-deliverysystem (Duragesic) ⁽¹⁸⁾. Because peak delivery does not occur until 12 hours, an alternateanalgesic must also be given initially. Transdermal fentanyl is helpful for patients who are unable (orunwilling) to take an oral opioid ⁽¹⁶⁾. Because of its potency, fentanyl must be used with extremecare, as deaths have been associated with its use. Physicians must emphasize to patients and theirfamilies the importance of following prescribing information closely, and members of the healthcareteam should monitor the use of the drug.

Equianalgesic Doses for Fentanyl Transdermal Patch ⁽³⁷⁾

Dose of Fentanyl	Total Dose of Morphine
	Oral Dose	Parenteral Dose
25 mcg/hr	25-65 mg/24 hr	8-22 mg/24 hr
50 mcg/hr	65-115 mg/hr	23-37 mg/24 hr
75 mcg/hr	116-150 mg/hr	38-52 mg/24 hr
100 mcg/hr	151-200 mg/hr	53-67 mg/24 hr
125 mcg/hr	201-225 mg/hr	68-82 mg/24 hr
150 mcg/hr	226-300 mg/hr	83-100 mg/24 hr

The use of methadone to relieve pain has increased substantially over the past few years,moving from a second-line or third-line drug to a first-line medication for severe pain in patients withlife-limiting diseases ⁽¹⁹⁾. Physicians must be well educated about the pharmacologic properties ofmethadone, as the risk for serious adverse events, including death, is high when the drug is notadministered appropriately ⁽²⁰⁾. One challenge in using methadone lies in the discrepancy betweenits duration of effect (four to six hours) and its elimination half-life (range: 15 to 40 hours; average: 24to 36 hours) ⁽²¹⁾. Consequently, if the dose of methadone is increased too rapidly or administered toofrequently, toxic accumulation of the drug can cause respiratory depression and death. When usingmethadone, extreme care must be taken when titrating the drug, and close evaluation of the patient isnecessary. Propoxyphene is an opioid that is chemically similar to methadone. It is not recommendedfor use because of toxicity even at therapeutic doses and a lack of efficacy compared with placebo oracetaminophen ⁽¹⁾, ⁽⁹⁾, ⁽¹⁵⁾. Similarly, meperidine should not be used in the palliative care settingbecause of limited efficacy and potential for severe toxicity. Agonist-antagonist opioids (nalbuphine,butorphanol, and pentazocine) are not recommended for use with pure opioids, as they compete withthem, leading to possible withdrawal symptoms. Unlike non-opioids, opioids do not have a ceilingeffect, and the dose can be titrated until pain is relieved or side effects become unmanageable. For an opioid-naïve patient or a patient who has been receiving low doses of a weak opioid, the initialdose should be low. Immediate-release morphine, hydromorphone, and oxycodone are the bestoptions ⁽⁹⁾. For a patient who has been taking a strong opioid and pain persists, the dose may betitrated up on a daily basis until pain is controlled. More than one route of opioid administration will beneeded by many patients during end-of-life care, but in general, opioids should be given orally, as thisroute is the most convenient and least expensive. For patients who have difficulty swallowing, thetransdermal route is preferred to the parenteral route. Intravenous and subcutaneous routes shouldbe reserved for patients who have pain crises or considerable intermittent pain ⁽²²⁾. Intramuscularinjections should be avoided.

Extra (rescue) doses of opioids are necessary for breakthrough pain. No individual opioid hasbeen shown to be better than another for breakthrough pain ⁽²³⁾. The most appropriate option is theimmediate-release form of the same opioid in routine use for pain control. This approach increasesefficacy while minimizing the risk of adverse effects. However, if fentanyl or methadone is theroutinely used drug, morphine or hydromorphone should be used for rescue doses. The rescue doseshould be 5% to 15% of the 24-hour dose ⁽²²⁾. Rescue doses may be repeated at intervalsdetermined by the route of administration; oral doses may be repeated every hour, subcutaneousdoses may be given every 30 minutes, and intravenous doses may be given every 5 to 10 minutes. Ifthree or more rescue doses are needed in a 24-hour period, the dose of the routinely used drugshould be titrated 25% to 100%, according to the intensity of the pain ⁽²²⁾. There is limited evidencethat transmucosal fentanyl provides more rapid pain relief for breakthrough pain than morphine.When pain responds poorly to escalated doses of an opioid, other approaches should be considered,including alternative routes of administration, use of alternate opioids (termed opioid rotation or opioidswitching), use of co-analgesics, and non-pharmacologic approaches. Opioid rotation has beenshown to offer improvement in more than 50% of patients who have chronic pain and a poorresponse to one opioid ⁽²⁴⁾. When changing the route of administration or the opioid, the dose of thenew opioid should be 50% to 75% of the equianalgesic dose ⁽²⁴⁾. Evidence suggests that thetraditionally recommended equianalgesic doses for the fentanyl transdermal patch are sub-therapeutic for patients with chronic cancer-related pain, and more aggressive approaches may bewarranted.

Side Effects of Opioids: Opioids are associated with many side effects, the most notableof which is constipation, occurring in nearly 100% of patients. The universality of this side effectmandates that once extended treatment with an opioid begins, prophylactic treatment with laxativesmust also be initiated. Tolerance to other side effects, such as nausea and sedation, usually developswithin three to seven days. Some patients may state that they are "allergic" to an opioid. It isimportant for the physician to explore what the patient experienced when the drug was taken in thepast, as many patients misinterpret side effects as an allergy. True allergy to an opioid is rare ⁽¹⁾, ⁽⁹⁾.Patients and families also fear that high doses of opioids can hasten death (the so-called doubleeffect); this is unsubstantiated by research. When opioids are prescribed, careful documentation ofthe patient’s history, examinations, treatments, progress, and plan of care are especially importantfrom a legal perspective. This documentation must provide evidence that the patient is functionallybetter off with the medication than without ⁽¹⁵⁾. In addition, physicians must note evidence of anydysfunction or abuse.

Adjuvant Agents: Adjuvant (co-analgesic) agents are often used in conjunction withopioids and are usually considered after the use of opioids has been optimized ⁽¹⁵⁾. The primaryindication for these drugs is adjunctive because they can provide relief in specific situations,especially neuropathic pain. Examples of adjuvant drugs are tricyclic antidepressants,corticosteroids, anticonvulsants, and local anesthetics (see table below). Tricyclicantidepressants are recommended for burning, stinging pain that is continuous or when underlyingdepression or insomnia is present ⁽²⁴⁾. Another class of antidepressants, selective serotoninreuptake inhibitors (SSRIs), has been relatively ineffective as analgesic agents ⁽²⁵⁾. Anticonvulsantsare suggested for neuropathic pain and lancinating, paroxysmal pain (25). Low doses of prednisonehave been found to be effective for vasculitic neuropathy, bone pain, and other cancer-relatedpain.

ADJUVANT ANALGESICS

Indications	Drugs	Typical Starting Dose *	Titration Recommendations
Spinal cord compression, malignant bone and nerve pain	Prednisone	20-40 mg PO, daily in divided doses
	Dexamethasone	4-16 mg PO, daily in divided doses
Dysesthetic and paroxysmal lancinating pain	Gabapentin	300-900 mg PO, 3-times daily	Increase by 100-300 mg every 1 to 3 days
	Phenytoin	200-300 mg PO, daily
	Carbamazepine	800 mg PO, daily	Increase every 3 days
	Lamotrigine	25 mg PO, daily	Increase by 25-50 mg/day per week
	Topiramate	25-50 mg PO, daily	Increase by 25-50 mg/day per week
	Oxcarbazepine	300 mg PO, 2 times daily	Increase by 300 mg every week
	Levetiracetam	500 mg PO, 2 times daily
Neuropathic and musculoskeletal pain	Amitriptyline Imipramine Doxepin Chlomipramine Desipramine Nortriptyline	10-25 mg PO, daily at bedtime	Increase to therapeutic dose of 50-150 mg daily in divided doses
Bone pain	Pamidronate	90 mg IV (over 2 hr), monthly
Visceral pain	Octreotide Scopolamine	100-600 mg IV or SC, daily 0.8-2.0 mg SC, daily
Second-line treatment of neuropathic pain (used with anticonvulsants)	Baclofen	5 mg PO, 2 times daily	Increase by 5 mg every 3 days to reach target dose of 40-80 mg/24 hr
Neuropathic pain refractory to anticonvulsants and opioids	Lidocaine	1-3 mg/kg IV, as loading dose (over 20 to 30 min), followed by infusion of 0.5-2 mg/kg/hr
Post-herpetic neuralgia	Capsaicin cream	0.075% cream, 4 times daily

*Doses given are guidelines; actual doses should be determined on an individual basis.

Non-Pharmacologic Management

Several non-pharmacologic approaches are therapeutic complements to pain-relievingmedication, lessening the need for higher doses and perhaps minimizing side effects. Theseinterventions can help decrease pain or distress that may be contributing to the pain sensation.Approaches include palliative radiotherapy, complementary/alternative methods, manipulative andbody-based methods, and cognitive/behavioral techniques. The choice of a specific non-pharmacologic intervention is based on the patient’s preference, which, in turn, is usually based on asuccessful experience in the past.

Palliative radiotherapy is effective for managing cancer-related pain, especially bone metastases⁽²⁶⁾. Bone metastases are the most frequent cause of cancer-related pain; 50% to 75% of patientswith bone metastases will have pain and impaired mobility. External beam radiotherapy is themainstay of treatment for pain related to bone metastases. At least some response occurs in 70% to80% of patients, and the median duration of pain relief has been reported to be 11 to 24 weeks. Ittakes one to four weeks for optimal therapeutic results ⁽²⁶⁾. However, palliative radiotherapy hasbecome a controversial issue. Although the benefits of palliative radiotherapy are well documentedand most hospice and oncology professionals believe that palliative radiotherapy is important, thistreatment approach is offered at approximately 24% of Medicare-certified freestanding hospices, withless than 3% of hospice patients being treated ⁽²⁷⁾. Reimbursement issues present a primary barrierto the use of palliative radiotherapy, and the cost of the treatment is prohibitive for many hospices,especially smaller ones. Among other barriers to the utilization of palliative radiotherapy are short lifeexpectancy, transportation issues, patient inconvenience, and lack of knowledge about the benefits ofpalliative radiotherapy in the primary care community ⁽²⁸⁾.

Two common complementary/alternative methods for pain relief are acupuncture and yoga.Acupuncture involves the insertion of needles beneath the skin to stimulate peripheral nerves toprovide pain relief. In general, relief occurs 15 to 40 minutes after stimulation. Relief seems to berelated to the release of endorphins and a susceptibility to hypnosis ⁽¹⁾. The efficacy of acupuncturefor relieving pain has not been proven, as study samples have been small. However, it may bebeneficial for musculoskeletal or nerve pain ⁽²⁹⁾. Hatha yoga is the branch of yoga most often used inthe medical context, and it has been shown to provide pain relief for patients who have osteoarthritisand carpal tunnel syndrome but it has not been studied in patients at the end of life. Yoga may helprelieve pain indirectly in some patients through its effects on reducing anxiety, increasing strength andflexibility, and enhancing breathing ⁽³⁰⁾. Yoga also helps patients feel a sense of control. Manipulativeand body-based methods include application of cold or heat, massage and vibration, positioning, andexercise. The application of cold and heat are particularly useful for localized pain and have beenfound to be effective for cancer-related pain caused by bone metastases or nerve involvement, aswell as for prevention of breakthrough incident pain ⁽¹⁾. Alternating application of heat and cold can besoothing for some patients, and it is often combined with other non-pharmacologic interventions. Coldcan be applied through wraps, gel packs, ice bags, and menthol. It provides relief for pain related toskeletal muscle spasms induced by nerve injury and inflamed joints. Cold application should not beused for patients with peripheral vascular disease. Heat can be applied as dry (heating pad) or moist(hot wrap, tub of water) and should be applied for no more than 20 minutes at a time, to avoid burningthe skin. Heat should not be applied to areas of decreased sensation or with inadequate vascularsupply, or for patients with bleeding disorders. Massage, which can be broadly defined as stroking,compression, or percussion, has led to significant and immediate improvement in pain in the hospicesetting ⁽³¹⁾. Both massage and vibration are primarily effective for muscle spasms related to tensionor nerve injury, and massage can be carried out with simultaneous application of heat or cold.Massage may be harmful for patients with coagulation abnormalities or thrombophlebitis.

Non-pharmacologic management of pain also includes cognitive/behavioral approaches such asrelaxation and breathing, imagery, and distractions. Focused relaxation and breathing can helpdecrease pain by easing muscle tension. Progressive muscle relaxation, in which patients follow asequence of tensing and relaxing muscle groups, has enabled patients to feel more in control and toexperience less pain ⁽¹⁾. This technique should be avoided if the muscle tensing will be too painful.Focused relaxation and breathing help provide distraction from pain. Other methods of distractioninclude reciting a poem, meditating with a calm phrase, watching television or movies, playing cards,visiting with friends, or participating in crafts. Imagery is among the most effective of the cognitivestrategies for pain relief and works especially well when it involves as many sites and senses aspossible ⁽³²⁾. Some research has shown that the efficacy of music therapy is similar to that ofrelaxation for relieving pain ⁽³²⁾.

Music therapy and art therapy are also becoming more widely used as non-pharmacologicoptions for pain management ⁽³³⁾. Music therapy works best when guided by an individual trained inusing it who can involve patients in selecting music to hear, playing music on instruments, or songwriting. Research suggests that art therapy contributes to a patient’s sense of well-being ⁽³³⁾.Creating art helps patients and families to explore thoughts and fears during the end of life. An arttherapist can help the creators reflect on the implications of the art work. Art therapy is especiallyhelpful for patients who have difficulty expressing feelings with words, for physical or emotional reasons.

Acronym for Pain Assessment and Management

The ABCDE acronym was written by Agency for Health Care Policy and Research, U.S.Department of Health and Human Services, Public Health Services for cancer pain. Although thisacronym is very appropriate for patients at end of life, regardless of their underlying disease.

A = Ask about pain regularly. Assess pain systematically.
B = Believe the patient and family in their reports of pain and what relieves it.
C = Choose pain control options appropriate for the patient, family and setting.
D = Deliver interventions in a timely, logical and coordinated fashion.
E = Empower patients and their families. Enable them to control their course to the greatest extent possible.

Legal and Ethical Issues Related to Pain Management

Fear of license suspension for inappropriate prescribing of controlled substances is alsoprevalent, and a better understanding of pain medication will enable physicians to prescribeaccurately, alleviating concern about regulatory oversight. Physicians must balance a fine line; on oneside, strict federal regulations regarding the prescription of schedule II opioids (morphine, oxycodone,methadone, hydromorphone) raise fear of Drug Enforcement Agency investigation, criminal charges,and civil lawsuits ⁽³⁴⁾. Careful documentation on the patient’s medical record regarding the rationalefor opioid treatment is essential ⁽³⁴⁾. On the other side, clinicians must adhere to the AmericanMedical Association’s Code of Ethics, which states that failure to treat pain is unethical. The codestates, in part: "Physicians have an obligation to relieve pain and suffering and to promote the dignityand autonomy of dying patients in their care. This includes providing effective palliative treatmenteven though it may foreseeably hasten death" ⁽³⁵⁾. In addition, the American Medical AssociationStatement on End-of-Life Care states that patients should have "trustworthy assurances that physicaland mental suffering will be carefully attended to and comfort measures intently secured" ⁽³⁵⁾.

Physicians should consider the legal ramifications of inadequate pain management andunderstand the liability risks associated with both inadequate treatment and treatment in excess. Theunder-treatment of pain carries a risk of malpractice liability, and this risk is set to increase as thegeneral population becomes better educated about the availability of effective approaches to painmanagement at the end of life ⁽¹⁵⁾. Establishing malpractice requires evidence of breach of duty andproof of injury and damages. Before the development of various guidelines for pain management, itwas difficult to establish a breach of duty, as this principle is defined by non-adherence to thestandard of care in a designated specialty. With such standards now in existence, expert medicaltestimony can be used to demonstrate that a practitioner did not meet established standards of carefor pain management. Another change in the analysis of malpractice liability involves injury anddamages. Because pain management can be considered as separate from disease treatment andbecause untreated pain can lead to long-term physical and emotional damage, claims can be madefor pain and suffering alone, without wrongful death or some other harm to the patient ⁽³⁶⁾.

Summary

Unrelieved pain is the greatest fear among patients with a life-limiting disease. This fear has beensubstantiated by findings from studies demonstrating under-treatment of pain among patients with avariety of chronic diseases and even for patients enrolled in palliative care or hospice programs.Healthcare professionals have acknowledged that the treatment of pain is inadequate. Healthcareprofessionals should strive to enhance their knowledge of key strategies to achieve high-quality painmanagement at the end of life, as detailed in this course.

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