What Options Are Available to Treat End-of-Life Pain?

Although not everyone who is dying is in pain, treating end-of-life pain is a crucial part of comfort care. If your loved one is in hospice, they should already have received a thorough pain assessment and, if needed, a prescription for one or more medications for pain. These medicines generally fall into one of several categories:

• Opiates — pain relievers made from the poppy plant such as morphine and codeine
• Opioids — synthetic or man-made opiates such as oxycodone, tramadol, methadone and fentanyl
• Anti-inflammatories — drugs that decrease inflammation, such as steroids (prednisone, dexamethasone) and nonsteroidal anti-inflammatory drugs (NSAIDS)
• Anticonvulsants such as gabapentin (Neurontin) and pregabalin (Lyrica) for nerve pain
• Bisphosphonates for bone pain and prevention of fractures in patients with bone cancer
• Antidepressants such as amitriptyline, and venlafaxine for nerve pain

Many patients receive a prescription for a long-acting opiate such as morphine as well as a shorter-acting opioid for breakthrough pain. Depending on the source and nature of the pain, the doctor may also prescribe one or more of the non-opioid medicines mentioned above. Always give the medicines on the schedule recommended by your hospice provider. If your loved one is still in pain, contact your hospice nurse. They will generally adjust the dose and/or frequency of the medications or add another drug. 

Remember, too, that physical pain is only one dimension of suffering that can occur during active and preactive dying. Depression, anxiety and fear can cause significant distress and exacerbate physical discomfort a great deal. Many patients benefit from the addition of an anti-anxiety medication such as Ativan or Xanax. These medicines can also help alleviate muscle spasms, which can be a source of pain as well. 

Finally, keep in mind that many nonpharmacologic interventions are very effective at alleviating physical pain. Depending on your loved one’s level of consciousness and general physical condition, you may try any of the following, all of which have been shown to lessen discomfort at the end of life:

• Therapeutic touch and massage
• Essential oil therapy
• Reiki
• Music therapy
• Bedside yoga and meditation

Simply being present with your loved one, talking to them softly, holding their hand or putting a cool cloth on their forehead or lips can also be very soothing and help them relax, which can lessen physical discomfort and psychological distress. 

Sources

“NCI Dictionary of Cancer Terms: Opiate”. National Cancer Institute. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/opiate 

“Gabapentin (Gralise, Neurontin) – Uses, Side Effects, and More”. WebMD. https://www.webmd.com/drugs/2/drug-14208-8217/gabapentin-oral/gabapentin-oral/details 

“Pregabalin (Lyrica) – Uses, Side Effects, and More”. WebMD. https://www.webmd.com/drugs/2/drug-93965/lyrica-oral/details 

“Bisphosphonates: Mechanism of Action and Role in Clinical Practice”. Mayo Clinic Proceedings.  https://pmc.ncbi.nlm.nih.gov/articles/PMC2667901/ 

“Pain, Pain, Go Away”. Psychiatry (Edgmont). https://pmc.ncbi.nlm.nih.gov/articles/PMC2729622/ 

“Ativan vs. Xanax: What are the differences?” Medical News Today. https://www.medicalnewstoday.com/articles/325771