Difficult Pain Control
In cases where pain is difficult to manage, consider the following.
Co-analgesics
Also called analgesic adjuvants, or adjuvant drugs, these are drug classes in which the usual indication is not pain relief, but can be used to supplement analgesics and improve pain control. Co-analgesics include:
antiepileptics e.g.
- carbamazepine
- gabapentin/pregabalin
antidepressants e.g.
- tricyclics
- seratonin and noradrenaline reuptake inhibitors (SNRIs)
corticosteroids
bisphosphonates
benzodiazepines
skeletal muscle relaxants
anticholinergics
For more information about the various co-analgesic drugs and their possible place in the treatment of your patient, discuss with your local specialist palliative care team. Also see complete coverage in Therapeutic Guidelines: Palliative Care
Bone metastases
Bone metastases may be an issue – have investigations been done to rule this out? Single dose or fractionated radiotherapy can relieve the pain of bone metastases in over 80% of cases.
Treatment of bone pain may require a combination of paracetamol, NSAIDs, opioids and co-analgesics.
Bisphosphonates can reduce incidence of complications and severity of bone pain.
- Note restricted PBS indications
Optimise non-pharmacological mx
Non-pharmacological management of pain includes:
- Warm baths
- Music
- Distraction
- Hot packs
- Sheep skin
- Massage
- Relaxation
- Reassurance
- Prompt use of analgesia
- Diligent bowel care
- Soft mattress
- Spiritual/pastoral care
- Physiotherapy
- Occupational therapy
Opioid switch
Opioid switching or rotation may be necessary due to:
Adverse drug effects such as
Nausea
Confusion
Drowsiness
Constipation
Potential benefit of one opioid over another e.g. methadone in difficult to control pain; fentanyl in renal impairment
Difficulty of administration e.g. fentanyl patch may be used where patient cannot swallow or is vomiting
Note: Start at less than the dose indicated in opioid comparative information tables as there may be incomplete cross-tolerance between opioids.