Principles of palliative care and pain medicine

The first step in managing pain is to do a total pain assessment. You may be asked to choose a number from 0 to 10 to rank your pain, with 0 being very mild pain and 10 being the worst possible pain you could have.

Keep in mind 3 important principles when deciding how to manage pain. First, pain should always be treated right away. A delay allows pain to get worse. Second, you should not be afraid of becoming addicted to pain medicine. If medicines are used in the right way under close supervision of a healthcare provider, this is rarely a problem. Of course, if you believe that you are losing control of how you are using pain medicines, discuss this with your healthcare provider right away. Third, most pain problems can be controlled by using the World Health Organization’s step-care approach: 

• Step 1. Start with a nonsteroidal anti-inflammatory drug (NSAID). Examples include over-the-counter drugs like ibuprofen and other NSAIDs that your healthcare provider may prescribe. An alternative to NSAIDs for step 1 pain is acetaminophen. This may be combined with another medicine to address pain, a side effect of treatment, or another symptom.

• Step 2. If pain continues or gets worse, your healthcare provider may prescribe an opioid medicine to treat mild to moderate pain. An example is hydrocodone. This type of opioid may be combined with a non-opioid pain reliever.

• Step 3. If pain continues or gets worse, your healthcare provider may prescribe a stronger opioid medicine. Examples include morphine and fentanyl.

Understanding opioid medicines

Opioid medicines work best for moderate to severe pain. A wide range of opioid medicines is available, and they can be taken in a variety of ways. One drawback of these medicines is that, over time, you will likely develop a tolerance to the one you’re taking and need higher doses to get the same effect. One way your healthcare provider may get around this problem is by switching the type, dose, or the way the medicine is given.

These are common ways in which opioid medicines can be given:

• Oral medicines. These can be taken in pill or liquid form and can be short-acting or long-acting (sustained release).

• Adhesive patch. This kind is applied to the skin to release medicine over time. An example of this is a fentanyl patch.

• Opioid medicine injection. This shot may be given under the skin or into a muscle.

• Opioid medicine IV. This medicine is given directly into the blood through an intravenous (IV) line.

• Medicine pump. Opioids can be given through a pump attached to an IV line that you control. This is called patient-controlled analgesia.

• Spinal injection. For pain that’s hard to control, a pain-control specialist may give an opioid medicine directly into the spinal cord area.

Understanding helper medicines

These medicines are called adjuvant analgesics. They can help control pain in certain cases. Commonly used adjuvant medicines include:

• Steroids. These are strong anti-inflammatory medicines that may help relieve pain by decreasing inflammation. They may be used along with other pain relievers for nerve, bone, or other types of pain.

• Antidepressants. Treating any existing depression can make pain easier to control. These medicines may also be useful in pain caused by nerve damage.

• Anticonvulsants. These medicines are usually used to control seizures, but they can also help control nerve-related pain.

• Local anesthetics. These are medicines that can block pain signals in the body. A pain specialist may inject a local anesthetic to block pain.

• Muscle relaxants. Muscle relaxants may be used along with pain medicine if pain is aggravated by muscle spasms.

• Antianxiety medicines. These medicines may be used along with pain medicine if tension or anxiety aggravate pain.

• Bisphosphonates. These medicines are sometimes used to prevent fractures in people whose cancer has spread to the bone. They can play a key role in relieving bone injury and pain.

Other pain control interventions

Surgery is often the last thing a patient or healthcare provider would consider at end of life. But at times, surgery can provide pain relief and increase function. Surgery’s primary goal can be to ease specific symptoms. For instance, a healthcare provider may recommend surgery to stabilize a hip fracture in someone with advanced cancer. The surgery is not going to treat the cancer or lengthen the patient’s life, but it may be the best way to reduce hip pain and improve mobility. Because surgery involves risk, the healthcare provider must clearly define treatment goals for both the patient and the patient’s family. Radiation therapy can also be used to ease pain and control symptoms.

If you or a loved one needs pain control and palliative care, many options are available. Work with your healthcare provider to find the right approach. You can also get help from a pain medicine specialist or a palliative care specialist. Remember: You have a right to be as free of pain as possible. There is no reason to let pain decrease your quality of life.