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End of life: optimum pain management

In patients at the end of life, pain management is important for maintaining a certain quality of life.

Treating pain in end-of-life adult patients requires an evaluation of the intensity of the pain and its repercussions. Listening to the patient, self-assessment of the pain by the patient and characterisation of the pain often make it possible to act on the causes of the pain, to tailor the treatment to the individual and to avoid anything that might trigger or exacerbate the pain.

Pain relief medication is classified according to three levels of effectiveness.

The main analgesics include paracetamol and nonsteroidal anti-inflammatories, which have more frequent and often more severe adverse effects.

Codeine, a first-line level-2 analgesic, belongs to the class of weak opioids. An alternative is dihydrocodeine, whose effectiveness is similar to that of codeine.

Morphine is the first-line level-3 analgesic. This strong opioid is available in several forms enabling its use to be adapted according to the type of pain and its intensity. It has a low risk of dependence in these circumstances, but it has adverse effects common to all opioids, particularly constipation, nausea and vomiting and neuropsychological disorders, even respiratory depression in the case of a sudden increase in the dosage and combination with benzodiazepines. Fentanyl is an alternative to morphine.

Other treatments should be considered in some cases: antidepressants or anti-epileptic drugs for neuropathic pain, cannabis derivatives for pain associated with muscular sclerosis, peripheral anaesthesia, even localised destruction of a nerve.

Helping patients to manage their treatment also allows them to better control pain and analgesic use.

©Prescrire 1 November 2011

"Analgesia for terminally ill adult patients" Prescrire Int 2011; 20 (121): 268-273. (pdf, subscribers only)

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