Care of Patients at the End of Life: Pharmacotherapeutic Management of Pain.

End-of-life care often involves management of pain. A patient's pain should be assessed using the Visual Analogue Scale, which uses a 0 to 10 score, with 0 indicating no pain and 10 the worst pain imaginable. Mild pain typically is managed with nonopioids (eg, acetaminophen, nonsteroidal anti-inflammatory drugs). More severe pain is managed with opioids. Opioid therapy should start with an immediate-release opioid to determine the dose needed to achieve pain control. This can be used to create a regimen with an extended-release formulation for daily pain management plus an immediate-release formulation for breakthrough pain. The breakthrough dose should be 10% to 15% of the total daily dosage administered every 2 to 3 hours. If there is a need to change opioids or convert from oral to parenteral opioids, a conversion table should be used to estimate the new dosage. Patients taking opioids often experience constipation, so also prescribing a laxative (eg, senna, sorbitol) is advised. Other adverse effects of opioids mainly occur when starting or increasing the dosage. These effects include nausea, sedation, neurotoxicity, and itching, and typically resolve in several days. Adjuvant drugs (eg, antidepressants, anticonvulsants) often are added to the opioid regimen, particularly for management of neuropathic pain.