Page 63 Guide to Pain Management in Low-Resource Settings

Principles of Palliative Care 51

ect of opi- fffrequent symptoms (Table 1). More detailed informa- Respiratory depression is a side e
tion on assessment and treatment of symptoms and on oids, but it does not contradict the use of opioids for
other areas of palliative care can be found in the clinical dyspnea. Dyspnea is most often related to elevated car-
guide to supportive and palliative care for HIV/AIDS in bon dioxide in the arterial blood, and less to reduced
sub-Saharan Africa, and in the WHO Integrated Man- oxygen. Opioids diminish the regulatory drive caused by
agement of Adult Illnesses Palliative Care module and elevated carbon dioxide levels, and in consequence pa-
related materials. tients will feel less hunger for air, even if breathing is not
Pain management in palliative care follows the improved. Opioids also reduce pain and anxiety, thus al-
rules of cancer pain management, with analgesic medi- leviating stress-induced dyspnea.
cations according to the principles of the World Health Dyspnea in cancer patients may also be caused
Organization at the center of the therapeutic approach. by mechanical impairment, for example from pleu-
usion. Mechanical release with pleural puncture ffOpioids such as oral morphine are the mainstay of pain ral e
management in palliative care in low-resource settings will produce rapid relief. Dyspnea can also be related
because they are relatively inexpensive and because ef- to severe anemia, leading to reduced oxygen transport
fective palliative care is not possible without the avail- capacity in the blood, and blood transfusions will alle-
ability of a potent opioid. Detailed information is avail- viate dyspnea in severely anemic patients, though most
able in Chapter 6. often only for a few days until the hemoglobin count
falls again. Oxygen will be helpful for control of dyspnea
Is treatment of other symptoms similar only in a minority of patients; however, other nonphar-
to pain management?
macological interventions may help, such as reposition-
Whilst there is no similar tool to the WHO analgesic ing of patients e.g., sitting in an upright position.
ladder to help treat other symptoms, many of the prin- In most patients simple measures such as com-
ow of air, for example by flciples applied to the pain management can also be ap- forting care, allowing free
plied to other symptoms. For example, reverse what is opening a window or providing a small ventilator or fan,
ective in the treatment of dyspnea. ffreversible and treat the underlying cause without in- will be very e
creasing the symptoms; use nonpharmacological drug
interventions—adjunctively or alone, as appropriate; How should you treat nausea?
c to the types of symptoms; and Nausea and vomiting can be treated with antiemetics fiuse medications speci
address associated psychosocial distress. Medication such as metoclopramide or low-dose neuroleptics such
ective if fffor symptom management should also be given by the as haloperidol. Corticosteroids can be most e
erent dosages available and gastrointestinal symptoms are caused by mechanical ffclock according to the di
ammation or cancer. Nondrug in- flwhere possible by mouth, thus making it easier for peo- obstruction from in
ple to continue with their medications at home, where terventions include nutritional counseling. Acupunc-
there is no health professional to give them injections. ture or acupressure at the inner side of the forearm
ective in some ff(acupuncture point “Neiguan”) is very e
How should you treat dyspnea?
ective as anti- ffpatients and has been proven to be as e
Whereas opioids are well established as the mainstay emetic drugs in clinical trials.
of pain management, it is less well known that opioids
ective for the treatment of dyspnea. How should you treat constipation? ffalso are very e
In opioid-naive patients, oral morphine (5–10 mg) or Constipation may be caused by intestinal manifestations
subcutaneous morphine (2.5–5 mg) will provide quick of the underlying disease, by drugs such as opioids or an-
ber diet, or firelief and may be repeated as required. Other opioids tidepressants, but also by inactivity, a low-
uid intake. Prophylactic treatment with laxatives flcan be used for this indication as well, with equipo- low
tent dosage. Patients already receiving opioids for pain should be prescribed for every patient receiving chronic
should have a dose increase to alleviate dyspnea. Con- opioid therapy. In contrast to other adverse events such
rst fitinuous dyspnea should be treated with a continuous as sedation, which most patients report only for the
nding rules few days after initiation of opioid therapy or a dose in- fiopioid medication, following similar dose-
as for pain management, although mostly with lower crease, patients do not develop tolerance to constipa-
starting dosages. tion. Th e peripheral opioid antagonist methylnaltrexone