WHO Analgesic Ladder
Essentially analgesia in palliative care is based on a three steps of increasingly strong pain relief. The decision to go to the next level of pain relief is based on whether the pain persists/increases whilst under each treatment.
- Step 1 - non-opioid: this is generally paracetamol or an NSAID (e.g. ibuprofen).
- Step 2 - weak opioid: usually, this will be codeine +/- a non-opioid.
- Step 3 - strong opioid: generally morphine +/- an opioid
Sometimes, in patients with severe end stage pain, they don't respond to morphine, or not after a certain level. In these situations, you can use methadone or ketamine, which can often alleviate pain where other methods have failed.
Route of administration
Various drugs have their standard routes of administration - for example, paracetamol is oral, and morphine is subcutaneous. Often, as patients get closer to death, they are unable to take an oral medication, or lack the muscle mass for intra-muscular injections, in which case an alternative administrative route is used.
Off license drugs
This is the most common time for off license drug use - administrating a drug in a form for which it is not licensed. In some cases, simply crushing a tablet makes it off license. As long as a doctor and a pharmacist sign in the notes why they have taken this route, it is allowed.
As pain gets worse, patients are commonly given syringe drivers, allowing them to administrate their own dose when needed. Many patients fear the syringe drivers, since it implies the end is near, and problems at the injection site are a disadvantage. That said, it is commonly used. You cannot use dexamethasone in a driver, because it reacts with the other drugs, nor chlorpromazine, because it causes skin irritation!
In a sample palliative care pain textbook, there are 15 chapters. 10 of them are dedicated to the social, psychological and spiritual manifestations of pain, only 5 are on the medical solutions. Thus, make sure the social issues are addressed.