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Pain therapy in palliative medicine

In addition to the right communication, willingness to talk and personal support, play Pain management and Symptom control a key role in palliative care. The latter means not only getting the pain under control, but also the other complaints with medication. A good treatment of pain and, embedded in it, an effective symptom control should make the last phase of life bearable and worth living.

Pain management

Pain therapy requires a lot of patience - from the doctor, patient and relatives, because pain is not just a physical sensation; it also has many psychological components that need to be "co-treated".

Pain therapy must start in good time, because pain leads the person affected to think more and more about his pain and his pain perception. “Breakthroughs in pain” must be avoided, the goal is to be completely free from pain!

Not all doctors are specialized in providing targeted, individual pain therapy. If necessary, specially trained palliative medicine specialists or outpatient pain therapists are available to provide support. Medicinal pain therapy can be supplemented by intelligent techniques such as pain pumps, targeted deactivation of individual nerves through surgical interventions, but also by complementary medical treatment methods. Palliative medical pain patients usually receive opioids (opium derivatives) such as morphine.

For fear of side effects, morphine and all other opioids used to be administered very cautiously. But also non-opioids such as B. Anti-inflammatory drugs (NSAIDs) have side effects, especially gastric ulcers and bleeding, which particularly affect the elderly. When used correctly, opioids are comparatively well-tolerated drugs. They are therefore part of the standard in palliative pain therapy. Some of the pain patients receive opioids not (only) because of the pain, but also because of the shortness of breath, B. in the most severe heart failure or lung cancer is in the foreground.

Targeted pain therapy is often made more difficult by the fact that many very old people can no longer clearly communicate their pain because they are too weak, too tired, speechless or confused. It is therefore important that all caregivers pay attention to indirect signs of pain, such as a tense face, a cramped posture, restlessness, constant ringing, confusion or even insomnia.

Basic drug rules. Oral administration of pain relievers is the most common method. When treating with painkillers, the following principles should be observed:

  • By mouth: Oral medication or pain patches are preferable to invasive procedures (injections).
  • After the clock: To permanently improve the symptoms, the painkillers should be taken at fixed times. This ensures that the next dose takes place before the previous dose loses its effectiveness. This principle is to prevent fear and constant memory of pain
  • Tailored to the patient: every patient has a different metabolism; You may have kidney or liver weakness at the same time. Therefore, the appropriate dose must be found for each patient. In the course of the treatment, this must be checked regularly and adjusted if necessary. In this way, the greatest possible benefit is achieved with the least possible side effects.
  • Preventing and treating side effects such as constipation and nausea. Other side effects such as tiredness should also be considered if they interfere with the everyday life of the person concerned.
  • Level scheme: Pain therapy should follow the WHO level scheme and be supplemented or intensified accordingly.

Keeping a pain diary is helpful for the doctor to adapt or intensify pain treatment. Such a diary shows how often, how long, how severe and during which activity pain occurs.

Pain patches. When using opioid-containing Pain patches (with fentanyl, e.g. in Durogesic®) some important things have to be considered. After the first stick on the skin, the effect is only slowly, within 12-24 hours. In the meantime, morphine preparations must be used as tablets. A constant effective level is achieved from the 24th hour to the 72nd hour. After that, the patch must be changed regularly - every third day. These plasters are unsuitable for the rapid treatment of severe pain or for strongly changing pain conditions. Pain peaks can also be treated with Sevredol.

When changing the plaster, areas of the skin that have already been used should remain unglued for at least seven days. What only a few patients know: If you have a fever, the medication delivery through the patch is increased by 30%. The same applies to the use of heating pads or direct sunlight.

The smallest strength of the Durogesic® patch is 12 µg / h. If this is still too much as a starting dose, there is a simple trick to help: the dose can be reduced by turning over a corner of the plaster. This trick is also propagated by the manufacturer. However, it must be taken into account that there can be strong fluctuations in the dosage (up to 30%). Cutting the plaster (regardless of its thickness) is not permitted due to the special structure of the plaster.

Left: Opioid pain patches in use Right: So-called pain lollipop for easier absorption of opioids through the oral mucosa
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A specialty in pain therapy are so-called Pain sucker (Actiq®). In these, fentanyl is absorbed through the cheek mucosa. This type of pain therapy is used to treat peaks in pain in patients with swallowing disorders or frequent vomiting.

  • If stage 3 opioid therapy according to the WHO scheme is necessary, those affected and their relatives must be informed about the effects and side effects of the treatment.
  • In patients who cannot sustain pain relief with medication, or in the case of certain tumor diseases (e.g. pancreatic cancer), special procedures such as neurolysis (destruction of pain-conducting nerve cells by injecting alcohol or phenol) or a chordotomy (cutting through of pain-conducting pathways at the spinal cord level) to help relieve pain.
  • In addition to the drug treatment of pain, the possibilities of physical treatment and psychological care should always be included in the overall concept. Very often such adjuvant measures can reduce the dose of highly effective opioids and thus also mitigate the side effects.
  • With the step-by-step approach to pain treatment for palliative patients, it should always be possible to eliminate excruciating pain and thus improve the quality of life of those affected and their relatives.

Symptom control

Common side effects during treatment with opiates are nausea, vomiting, and constipation. Severe constipation can lead to very uncomfortable and excruciating abdominal pain. Constipation as well as nausea or vomiting can be treated very well as a preventive measure.

Nausea and vomiting in palliative medicine have very different causes. Common causes should be ruled out prior to purely symptomatic treatment. In addition to drug side effects (especially opioid use), severe constipation, intestinal obstruction or an increased calcium level (e.g. due to increased bone breakdown in bone metastases) are common causes of nausea and recurring vomiting.

Kidney failure, the consequences of chemotherapy or severe pain, but also sensory impressions such as Other important causes of nausea and vomiting are bad smells or feelings of disgust when looking at food. In addition to drugs to combat nausea (antiemetics), many non-drug measures can also help, e.g. B. Regular fresh air supply in the rooms and an as upright posture as possible to avoid pressure on the stomach.

If vomiting occurs several times a day, drugs should no longer be taken in tablet form. Injection under the skin (subcutaneous) is an alternative.

Constipation and intestinal obstruction. Sedentary lifestyle and pain treatment with opioids are common causes of constipation, which in the worst case can lead to excruciating constipation.

If food is consumed without problems, constipation can be avoided with a high-fiber diet and plenty of fluids. Regular walks also help balance peristalsis.

If these measures are not possible or do not have an adequate effect, laxatives must be taken.

A special case of constipation is when an intestinal tumor completely or partially obstructs the intestine. Typical signs are frequent alternation between constipation and diarrhea. If the suspicion is confirmed, a palliative patient may also have to be urgently advised to have an operation involving the creation of an artificial intestinal outlet in order to avert a painful death.

Drug treatment in the dying phase

In the last phase of life (dying phase) the treatment mandate for the doctors changes. The focus is no longer on diagnostic measures, sometimes stressful interventions, punctures or treatment methods. The demand of the dying person and his relatives is a dignified death without excruciating suffering.

In the last phase of a fatal illness, pain, restlessness, shortness of breath, nausea / vomiting, and rattle when breathing are caused by water retention in the lungs are most common.

Whenever possible, the medication should always be given by mouth. If this is no longer possible, for example in the case of recurring vomiting, unconsciousness or difficulty swallowing, you can z. B. switch to continuous subcutaneous administration with the help of a drug pump.

Authors

Dipl.-Pflegew. (FH) Carmen Happe, Ruth Mamerow, Dr. med. Arne Schäffler in: Gesundheit heute, edited by Dr. med. Arne Schäffler. Trias, Stuttgart, 3rd edition (2014). Revision and update: Dr. med. Sonja Kempinski | last changed on at 15:31