Pain
Non-pharmacologic management:
Massage, heat/cold stimulation
Acupuncture/acupressure
Exercise (as tolerated); physical therapy
Biofeedback
Distraction/imagery/hypnosis
Diaphragmatic breathing
Meditation
Aromatherapy
Pharmacologic management:
WHO Pain Ladder (see below)
Choose the simplest, most effective, and least painful route for pain medication if possible
General principles of rapid titration of opioids at the end-of-life:
Identify prescribing/administering team members (often done in conjunction with PACT team)
Notify the pharmacy
There is NO CEILING DOSE
Dosing:
Loading dose:
For the patient already on opioids, administer 10% of total opioids from preceding 24 hours
For patient not already receiving opioids: administer typical starting opioid dose
Subsequent dosing:
Repeat initial dose every 10 minutes until comfort is achieved, increase the dose by 50% every third dose
Once comfort is achieved, start continuous infusion:
Recommended hourly rate = total opioid administered during rapid titration divided by 6 (which is 2x half-life in hours)
Increase infusion and intermittent dosing by 30-50% for moderate increase in symptoms
Consider adjunctive therapy (see below)
For refractory symptoms, consider palliative sedation (requires PACT or pain team involvement)
| Drug Class | Adjuvant Agents |
|---|---|
| Neuropathic Agents |
Tricyclic Antidepressants - Nortriptyline - Amitryptiline Gabapentoids - Gabapentin - Pregabalin |
| Benzodiazepines |
Diazepam Clonazepam |
| Alpha-2 Agonists |
Clonidine Dexmedetomidine (0.1 - 1mcg/kg/h IV) |
| NMDA Antagonists | Ketamine (0.05 - 0.1mg/kg/h IV or 0.25 - 0.5mg/kg PO q6-8h) |
| Antispasmodics |
Baclofen (2.5 - 5mg PO q8h) Increase q3 days by 5-15mg/day to max 60-80mg/day) |
| Topical Analgesics | Lidocaine patch |
| Steroids (spinal cord compression, ICP, bowel wall edema, hepatic distension) |
Prednisone (bone pain) Dexamethasone 1-2mg/kg (max 50-100mg) IV load, then 0.1mg/kg (max 4mg) IV q6h |
| WHO Pain Ladder | Drug | Dosing | Route |
|---|---|---|---|
|
Step 1: Mild Pain (Non-opioid +/- adjuvant) |
Acetaminophen |
10 - 15mg/kg q4-6h (max 75mg/kg/day) |
PO/PR/IV |
| Ibuprofen |
6 - 10mg/kg q6-8h (max 400-600mg/day) |
PO | |
| Naproxen |
5 - 7mg/kg q12h (max 250-400mg/day) |
PO | |
| Ketorolac |
0.3 - 0.5mg/kg q6-8h (15 or 30mg/dose for 5 days) |
IV | |
| Celecoxib |
1-2mg/kg (max 100mg/dose) |
PO | |
|
Step 2: Moderate - Severe Pain (or uncontrolled after Step 1) (Non-opioid ATC + opioid + adjuvant agent) |
Morphine Sustained-Release form |
PO: 0.2 - 0.3mg/kg q3-4h (10-15mg/dose max) IV: 0.05 - 0.1mg/kg q2-4h (2.5 - 5mg/dose max) |
PO/SL IV/SC PR |
| Hydromorphone |
PO: 0.04 - 0.06mg/kg q3-4h (1-2mg/dose max) IV: 0.015mg/kg q2-4h (0.2 - 0.6mg/dose max) |
PO/SL IV/SC |
|
| Fentanyl |
0.5 - 2mcg/kg q30min (25-75mcg/dose max) |
IV/SC | |
|
Oxycodone Sustained-Release form |
0.1 - 0.2mg/kg q4-6h (5 - 10mg/dose max) |
PO |
| Drug | PO (mg) | IV (mg) |
|---|---|---|
| Morphine | 30 | 10 |
| Oxycodone | 20 | N/A |
| Hydromorphone | 7.5 | 1.5 |
| Fentanyl | N/A | 0.1 (100mcg) |
Opioid Conversion Table
Opioid Side Effects and Management
| Constipation |
- Bowel regimen for every patient (stool softener + stimulant) - Refractory: naloxone (0.25 - 2mcg/kg/h) or methylnaltrexone (0.15mg/kg for max 8-12mg) q48h SC |
| Nausea/Vomiting |
- Generally improves after several days - Anti-emetics (see Nausea/Vomiting page) - Opioid rotation |
| Pruritis |
- Ondansetron 0.15mg/kg PO/IV (max 4-8mg) - Nalbuphine 0.01 - 0.02mg/kg IV q6h (max 1.5mg) - Naloxone 0.25 - 2mcg/kg/h * Antihistamines are NOT effective |
|
Myoclonus Hallucinations Hyperalgesia |
- Decrease dose if adequate analgesia - Opioid rotation |