Refractory pain in palliative care
Reassess patients with palliative care needs who have poorly controlled pain despite seemingly adequate management—see Key questions to assess poor response to pain management in palliative care for key questions to assess poor response to pain management. See also Approach to managing pain in palliative care.
For patients with limited or less than optimal pain relief, the power of the therapeutic relationship is important; reassure the patient they will not be abandoned (see Distress in palliative care).
Generally, the pathophysiology of pain in patients with palliative care needs is likely to have a combination of nociceptive and neuropathic mechanisms, particularly if it is due to damaged nerve tissue. Not all pain is opioid-responsive. If there is only partial response to paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, and breakthrough doses of opioids are providing limited benefit, consider adding an adjuvant analgesicKane, 2018van den Beuken-van Everdingen, 2017. Consider deprescribing analgesics that are not providing benefit—see Principles of medication rationalisation in palliative care.
Consider early referral to a specialist palliative care service if pain is not controlled with opioid and adjuvant analgesics. Factors contributing to refractory pain in palliative care lists other factors that may prompt early referral. Early multidisciplinary management can:
- minimise complications
- reduce the pathophysiological and psychosocial consequences of prolonged uncontrolled pain
- increase the likelihood of patients being able to maintain their independence and normal social relationships.
The following factors may contribute to refractory pain and prompt consideration of early referral to a specialist palliative care service:
- neuropathic pain
- incident pain
- multiple concurrent pains and pain mechanisms
- longstanding pain
- poor response to multimodal analgesia
- analgesic avoidance because of adverse effects
- history of a disorder of substance use
- significant challenges causing distress.
Other treatment options for refractory pain that require specialist advice include:
- interventional therapies such as nerve blocks, epidural or intrathecal analgesia1
- ketamineBell, 2017Cohen, 2018
- methadone
- radiotherapy, surgery or anticancer drugs for cancer pain.
Clinicians managing a patient with poorly controlled pain may feel inadequate and that they are failing the patient. Do not hesitate to seek the assistance and support of other practitioners—see Healthcare professional wellbeing in palliative care.