Study Points
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Study Points
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- Describe the etiology of pain at the end of life and issues in effective pain management.
- Assess pain accurately through use of clinical tools and other strategies, including the use of an interpreter.
- Select appropriate pharmacologic and/or nonpharmacologic therapies to manage pain in patients during the end-of-life period.
The reported prevalence of pain at the end of life is greatest among adults with
Click to ReviewThe prevalence of pain at the end of life has been reported to range from 8% to 96%, occurring at higher rates among people with cancer than among adults with other life-limiting diseases [19,20]. Pain can be caused by a multitude of factors and is usually multidimensional, with pain frequently being exacerbated by other physical symptoms and by psychosocial factors, such as anxiety or depression [8].
Which of the following is the most reliable indicator of pain?
Click to ReviewPain should be assessed routinely, and frequent assessment has become the standard of care [8]. Pain is a subjective experience, and as such, the patient's self-report of pain is the most reliable indicator. Research has shown that pain is underestimated by healthcare professionals and overestimated by family members [8,21]. Therefore, it is essential to obtain a pain history directly from the patient, when possible, as a first step toward determining the cause of the pain and selecting appropriate treatment strategies. When the patient is unable to communicate verbally, other strategies must be used to determine the characteristics of the pain, as will be discussed.
Research has shown that pain is
Click to ReviewPain should be assessed routinely, and frequent assessment has become the standard of care [8]. Pain is a subjective experience, and as such, the patient's self-report of pain is the most reliable indicator. Research has shown that pain is underestimated by healthcare professionals and overestimated by family members [8,21]. Therefore, it is essential to obtain a pain history directly from the patient, when possible, as a first step toward determining the cause of the pain and selecting appropriate treatment strategies. When the patient is unable to communicate verbally, other strategies must be used to determine the characteristics of the pain, as will be discussed.
Generalized pain is usually indicative of
Click to ReviewQuestions should be asked to elicit descriptions of the pain characteristics, including its location, distribution, quality, temporal aspect, and intensity. In addition, the patient should be asked about aggravating or alleviating factors. Pain is often felt in more than one area, and physicians should attempt to discern if the pain is focal, multifocal, or generalized. Focal or multifocal pain usually indicates an underlying tissue injury or lesion, whereas generalized pain could be associated with damage to the central nervous system. Pain can also be referred, usually an indicator of visceral pain.
According to the World Health Organization (WHO) ladder, pain should be managed
Click to ReviewThe WHO analgesic ladder, introduced in 1986 and disseminated worldwide, remains recognized as a useful educational tool but not as a strict protocol for the treatment of pain. It is intended to be used only as a general guide to pain management [31]. The three-step analgesic ladder designates the type of analgesic agent based on the severity of pain (Figure 1) [31]. Step 1 of the WHO ladder involves the use of nonopioid analgesics, with or without an adjuvant (co-analgesic) agent, for mild pain (pain that is rated 1 to 3 on a 10-point scale). Step 2 treatment, recommended for moderate pain (score of 4 to 6), calls for a weak opioid, which may be used in combination with a step 1 nonopioid analgesic for unrelieved pain. Step 3 treatment is reserved for severe pain (score of 7 to 10) or pain that persists after Step 2 treatment. Strong opioids are the optimum choice of drug at Step 3. At any step, nonopioids and/or adjuvant drugs may be helpful. Some consider this model to be outdated and/or simplistic, but most agree that it remains foundational. It can be modified or revised, as needed, to apply more accurately to different patient populations.
The maximum recommended dose of acetaminophen is
Click to ReviewNonopioid analgesics, such as aspirin, acetaminophen (Tylenol), and nonsteroidal anti-inflammatory drugs (NSAIDs), are primarily used for mild pain (Step 1 of the WHO ladder) and may also be helpful as coanalgesics at Steps 2 and 3. Acetaminophen is among the safest of analgesic agents, but it has essentially no anti-inflammatory effect. Toxicity is a concern at high doses, and the maximum recommended dose is 3–4 g per day [8]. Acetaminophen should be avoided or given at lower doses in people with a history of alcohol abuse or renal or hepatic insufficiency [8].
The onset of action of fentanyl transdermal patch is
Click to ReviewOPIOIDS FOR THE MANAGEMENT OF PAIN IN ADULTSa
Drug Typical Starting Doseb Onset of Action Duration of Action Codeine 15–60 mg 30 to 60 minutes 4 to 6 hours Hydrocodone 2.5–10 mg 10 to 20 minutes 4 to 8 hours Morphine, immediate release 15–30 mg 15 to 30 minutes (oral) 5 to 10 minutes (IV) 3 to 6 hours Oxycodone, immediate release 5–10 mg 10 to 30 minutes 3 to 4 hours Oxymorphone, sustained release 10 mg 5 to 10 minutes 8 to 12 hours Hydromorphone 2–4 mg 15 to 30 minutes 4 to 5 hours Methadone 5–10 mg 30 to 60 minutes 4 to 6 hours Tapentadol 50–100 mg <60 minutes 4 to 6 hours Tapentadol, extended release 50–100 mg — — Fentanyl (buccal tablet) 100–200 mcg 5 to 15 minutes 2 to 4 hours Fentanyl (transdermal patch) 25 mcg/hour (worn for 3 days) 12 to 18 hours 48 to 72 hours Buprenorphine (transdermal patch) 5–10 mcg/hour (worn for 7 days) — — aAll information is given for oral formulations unless otherwise specified. bDoses given are guidelines for opioid-naïve patients; actual doses should be determined on an individual basis. According to the WHO ladder, which of the following is the opioid considered to be the first-line treatment for Step 3 pain management?
Click to ReviewMorphine is considered to be the first-line treatment for a Step 3 opioid [34]. Morphine is available in both immediate-release and sustained-release forms, and the latter form can enhance patient compliance. The sustained-release tablets should not be cut, crushed, or chewed, as this counteracts the sustained-release properties. Morphine should be avoided in patients with severe renal failure [28].
What is the most common side effect of opioid use?
Click to ReviewOpioids are associated with many side effects, the most notable of which is constipation, occurring in nearly 100% of patients. The universality of this side effect mandates that once extended treatment with an opioid begins, prophylactic treatment with laxatives must also be initiated. Tolerance to other side effects, such as nausea and sedation, usually develops within three to seven days. Some patients may state that they are "allergic" to an opioid. It is important for the physician to explore what the patient experienced when the drug was taken in the past, as many patients misinterpret side effects as an allergy. True allergy to an opioid is rare [8]. Opioid rotation may also be done to reduce adverse events.
Which of the following is NOT a barrier to the use of palliative radiotherapy?
Click to ReviewHowever, palliative radiotherapy has become a controversial issue. Although the benefits of palliative radiotherapy are well documented and most hospice and oncology professionals believe that palliative radiotherapy is important, this treatment approach is offered at approximately 24% of Medicare-certified freestanding hospices, with less than 3% of hospice patients being treated [56,57,58]. As previously noted, reimbursement issues present a primary barrier to the use of palliative radiotherapy [56,57,58]. Among other barriers are short life expectancy, transportation issues, patient inconvenience, and lack of knowledge about the benefits of palliative radiotherapy in the primary care community [55,56,57,59].
- Back to Course Home
- Participation Instructions
- Review the course material online or in print.
- Complete the course evaluation.
- Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.