Drugs in Palliative Care

·        Pain control.

·        Oral morphine.

Pain Control

1.       Analgesics should be given regularly, adjusted to the patient’s need to prevent pain and not only to suppress it.

2.       Suppression of existent pain requires larger doses, particularly where the pain has generated anxiety and fear.

3.    A dose of analgesic should be left accessible to the patient, especially at night.

4.       Control of severe pain without objectionable sedation can be achieved in palliative care by morphine with adjuvant drugs in up to 80% of patients.

5.    Oral use preserves patients’ independence as well as reducing the unpleasantness of frequent injections.

Oral Morphine for pain in Palliative care

1.    Oral treatment allows independence and can be provided at home where most patients will prefer to die.

2.    A simple aqueous solution may be used initially, the strength being adjusted to give a volume of 5 – 10ml per dose.

3.       Alternatively, sustained-release tablets may be preferred, suppositories or buccal formulations.

4.    If the first dose is not more effective than previous medication, increase the second dose or third dose.

5.    If the pain is not more than 90% controlled in the first 24h increase the dose by 50%.

6.       Dosing:

a.       Arbitrary fixed dosage is inappropriate; doses and frequency should be adjusted to meet the patients’ need.

b.       Breakthrough pain when the patient is taking a sustained-release preparation may be controlled by an additional dose of the aqueous solution.

c.       Change to morphine from other high-efficacy opioids; higher starting doses of oral morphine will be needed.

d.    A larger dose at night or an added hypnotic may allow the patient to pass the night without waking in pain.

7.       Common symptoms:

a.       Constipation will occur.

b.       Initial drowsiness and confusion are common and usually pass off.

c.       Initial nausea and vomiting may occur; an antiemetic controls it.

d.       Myoclonus may occur, perhaps promoted by concurrent use of antidepressants or neuroleptics.

e.       Respiratory depression is seldom a problem.

f.     Both psychological and physical dependence occurs.

g.       Acquired tolerance is dealt with by increasing the dose.

h.       Transfer from the oral to the subcutaneous route may become necessary, e.g. due to difficult swallowing, vomiting.

8.       Adjuvant drugs:

a.       Phenothiazines are antiemetic, antianxiety and sedative agents and they may change the affective response to pain.

b.       Tricyclic antidepressants have a morphine-sparing effect even in the absence of an effect or mood.

c.       Amphetamines elevates mood and enhances analgesia.

Control of Symptoms in Dying patients