Monitoring analgesic therapy in palliative care
Regularly review analgesic therapy in patients with palliative care needs; evaluate effectiveness and tolerability by assessing:
- duration of effectiveness of each dose
- breakthrough pain and incident pain
- number of analgesic doses required for breakthrough pain or intermittent pain in a 24-hour period (if relevant)
- reduction in pain severity
- other factors that are meaningful to the patient (eg social interaction, mood, mobility, tablet burden)
- adverse effects.
An analgesic is considered effective if the patient has met their goals of care (see Pain management plans in palliative care), which may be a meaningful reduction in pain, or improved mobility, function or social engagement with limited or tolerable adverse effects and no aberrant behaviour1.
Analgesic effectiveness varies markedly and it is often difficult to attribute benefit to a single intervention (eg an analgesic) because an improvement in function or pain may be due to the analgesic, a placebo effect or concurrent nonpharmacological strategies. If pain control is not optimal (ie frequent breakthrough or intermittent pain is occurring), consider and address any relevant factors listed in Key questions to assess poor response to pain management in palliative care.
When adjusting analgesic therapy, it is usually better to only make one change at a time so that benefit and adverse effects can be more easily assessed. Decisions about management for inadequate pain control may require advice from a palliative care specialist—see Refractory pain in palliative care.
Has the pain been diagnosed correctly (eg is there a neuropathic component [NB1])?
Has the patient had enough rest or sleep?
Does the patient have unaddressed psychosocial, spiritual or existential needs?
Is the type of pain responsive to the analgesic used? [NB2]
Is the route of administration appropriate (eg could the patient have impaired gastrointestinal absorption)?
Is the regular analgesic regimen adequate? [NB3]
Has the regular analgesic regimen been disrupted? [NB4]
Does the patient understand and adhere to the drug regimen?
- Is the patient experiencing an adverse effect? [NB5]
- Has the patient’s cognition changed as a result of the life-limiting illness?
- Is the patient having trouble with the current formulation (eg difficulty swallowing)?
Could the patient have developed opioid-induced hyperalgesiaEisenberg, 2015Higgins, 2019? [NB6]
Has the disease progressed?
Could the pain be caused by an acute injury (eg impending or pathological bone fracture)?
NB1: It is generally better to introduce an adjuvant analgesic for neuropathic pain early, rather than escalating the opioid dose.
NB2: Deprescribe ineffective analgesic therapy.
NB3: For advice on increasing regular opioid therapy, see Increasing the dose of regular opioid therapy in palliative care.
NB4: For patients who have been taking opioids long term, an interruption in therapy may cause a withdrawal syndrome. This is a particular concern when moving patients between care settings (eg from home to hospital, between hospitals, discharge from hospital), when doses may be missed—for advice, see Medication management when moving between care settings. If the patient’s usual opioid is not available in a timely manner, conversion to an alternative, dose-equivalent option may be needed—see Switching opioids in palliative care. Specialist input may be required.
NB5: Consider whether adverse effects could be caused by kidney or liver dysfunction resulting in accumulation of opioid metabolites.
NB6: Consider reducing the opioid dose—seek specialist palliative medicine advice.