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Course # 97142 • Assessment and Management of Pain at the End of Life


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  1. Describe the etiology of pain at the end of life and issues in effective pain management.
  2. Assess pain accurately through use of clinical tools and other strategies, including the use of an interpreter.
  3. Select appropriate pharmacologic and/or nonpharmacologic therapies to manage pain in patients during the end-of-life period.
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1. The reported prevalence of pain at the end of life is greatest among adults with
A) cancer.
B) COPD.
C) diabetes.
D) heart failure.

ETIOLOGY

The 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].


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2. Which of the following is the most reliable indicator of pain?
A) Patients' self-report
B) Results of physical examination
C) Results of functional assessment
D) Results of multidimensional assessment

ASSESSMENT

Pain 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.


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3. Research has shown that pain is
A) overestimated by patients.
B) overestimated by healthcare professionals.
C) underestimated by healthcare professionals.
D) underestimated by patients' family members.

ASSESSMENT

Pain 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.


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4. Generalized pain is usually indicative of
A) tissue lesions.
B) underlying tissue injury.
C) central nervous system damage.
D) All of the above

ASSESSMENT

Questions 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.


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5. According to the World Health Organization (WHO) ladder, pain should be managed
A) with only nonopioids for steps 1 and 2.
B) in a stepwise progression from step 1 to step 3.
C) in a manner according to the severity of the pain.
D) with opioids given around the clock and nonopioids given on an as-needed basis.

MANAGEMENT

The pharmacologic management of pain is best achieved with use of the WHO three-step analgesic ladder, which designates the type of analgesic agent based on the severity of pain (Figure 1) [30]. Step 1 of the WHO ladder involves the use of nonopioid analgesics, with or without an adjuvant (coanalgesic) 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.


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6. The maximum recommended dose of acetaminophen is
A) 1–1.5 g per day.
B) 3–4 g per day.
C) 5–7 g per day.
D) 8– 10 g per day.

MANAGEMENT

Nonopioid 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].


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7. The onset of action of fentanyl transdermal patch is
A) 5 to 10 minutes.
B) 30 to 60 minutes.
C) 8 to 12 hours.
D) 12 to 18 hours.

MANAGEMENT

OPIOIDS FOR THE MANAGEMENT OF PAIN IN ADULTSa

DrugTypical Starting DosebOnset of ActionDuration of Action
Codeine15–60 mg30 to 60 minutes4 to 6 hours
Hydrocodone2.5–10 mg10 to 20 minutes4 to 8 hours
Morphine, immediate release15–30 mg
15 to 30 minutes (oral)
5 to 10 minutes (IV)
3 to 6 hours
Oxycodone, immediate release5–10 mg10 to 30 minutes3 to 4 hours
Oxymorphone, sustained release10 mg5 to 10 minutes8 to 12 hours
Hydromorphone2–4 mg15 to 30 minutes4 to 5 hours
Methadone5–10 mg30 to 60 minutes4 to 6 hours
Tapentadol50–100 mg<60 minutes4 to 6 hours
Tapentadol, extended release50–100 mg
Fentanyl (buccal tablet)100–200 mcg5 to 15 minutes2 to 4 hours
Fentanyl (transdermal patch)25 mcg/hour (worn for 3 days)12 to 18 hours48 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.

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8. According to the WHO ladder, which of the following is the opioid considered to be the first-line treatment for Step 3 pain management?
A) Fentanyl
B) Morphine
C) Methadone
D) Oxycodone

MANAGEMENT

Morphine is considered to be the first-line treatment for a Step 3 opioid [32]. 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].


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9. What is the most common side effect of opioid use?
A) Allergy
B) Nausea
C) Sedation
D) Constipation

MANAGEMENT

Opioids 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.


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10. Which of the following is NOT a barrier to the use of palliative radiotherapy?
A) Transportation issues
B) Patient inconvenience
C) Longer life expectancy
D) Lack of knowledge in the primary care community

MANAGEMENT

However, 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 [53,54,55]. As previously noted, reimbursement issues present a primary barrier to the use of palliative radiotherapy [53,54,55]. 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 [52,53,54,56].


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