Volume 107, Issue s4

Pain management in end-of-life care presents a unique set of opportunities for patients and physicians. Physicians will encounter patients at the end of life regardless of type of specialty practice. Symptom relief is the concern of all physicians. Knowledge of “total pain” concepts along with basic end-of-life pain management offers much to patients and their families. Osteopathic principles and treatment philosophy complement quality pain management in end-of-life care. Physicians providing supportive care can assist patients and their families with comfort at the end of life. Good pain management at the end of life enhances the patient-physician relationship.

The elderly are often untreated or undertreated for pain. Barriers to effective management include challenges to proper assessment of pain; underreporting by patients; atypical manifestations of pain in the elderly; a need for increased appreciation of the pharmacokinetic and pharmacodynamic changes of aging; and misconceptions about tolerance and addiction to opioids. Physicians can provide appropriate analgesia in geriatric patients by understanding different types of pain (nociceptive and neuropathic), and correctly using nonopioid, opioid, and adjuvant medications. Opioids have become more widely accepted for treating older adults who have persistent pain, but such use requires physicians have an understanding of prevention and management of side effects, opioid titration and withdrawal, and careful monitoring. Placebo use is unwarranted and unethical. Nonpharmacologic approaches to pain management are essential and include osteopathic manipulative treatment, cognitive behavioral therapy, exercise, and spiritual interventions. The holistic and interdisciplinary approach of osteopathic medicine offers an approach that can optimize effective pain management in older adults.

Methadone hydrochloride is an effective, inexpensive, and relatively safe opioid to use in treatment of patients with chronic pain. Because it is the only long-acting analgesic available in liquid form, methadone is especially valuable in management of pain during the final stages of life. However, because methadone has an inherently long duration of action with wide variations, a possibility of accumulation and overdosage exists. Therefore, physicians must be judicious and conscientious when prescribing this opioid. Physicians must also closely monitor patients during the titration phase and educate them with regard to basic pharmacologic properties and potential side effects. A plan to start at low doses and proceed slowly is applicable to methadone.

People are living longer but are dying with more disabilities, often in nursing homes. Identification of those who are dying needs to be quicker to allow discussion of goals of care and to meet their individual needs at a higher level. Pain is pervasive and undertreated in general, but institutionalized individuals are even at greater risk of receiving inadequate analgesia. Competing goals of providing good-quality palliative care while meeting federal and state expectations of improving or maintaining function can create dilemmas for those caring for terminally ill patients in nursing homes. Physicians play a critical role in improving communication between the family and the healthcare team during the transition from rehabilitative to palliative care. Hospice can be a valuable partner in the delivery of excellent pain and symptom management in end-of-life care.

Managing symptoms at end of life can be one of the more challenging and rewarding aspects of medical care. Pain management in particular can be made difficult from an unlikely source. Surrounded by myth, misconception, and cultural bias, opiates remain the mainstay of treatment. Frequently, patients themselves may be the most formidable barrier to their effective use. Presentation of a reality-based case serves as the basis for exploring some of these attitudes and beliefs that may be a stumbling block to opiate use in effective pain management. The inhibiting fear associated with prescribing drugs classified as “narcotic” is illustrated through 10 common misconceptions regarding their use and is characterized by the term Opiophobia . Not all the misconceptions originate from patients, but also from family members, cultural and regulatory agency norms, and even physicians themselves. A brief discussion follows each of such flawed concepts as “morphine use indicates death is imminent,” “enduring pain enhances character,” hospitalization is required for effective pain management,” and “opiate use always leads to addiction.” Regarding the hot button issue of addiction, a glossary is provided to help in distinguishing nonaddiction etiologies that explain the frequent need for dosing increases. The formal recognition of hospice and palliative medicine as a certified sub-specialty confirms the notion that it is the duty of physicians to provide optimal care through the dying process. Undoubtedly, evidence-based guidelines will lead to new standards of practice improving end-of-life care. This article adds perspective to past practices and opens the door to adding perspective to new ones.

The following policy statement was adopted by the American Osteopathic Association's House of Delegates in 2005. This statement was drafted by the association's Council on Palliative Care Issues, which at that time was called the End-of-Life Care Committee. This statement has been modified to adhere to the house style of JAOA—The Journal of the American Osteopathic Association.

A number of organizations have advised against the use of placebo substitution, including the American Pain Society, Agency for Healthcare Policy and Research, World Health Organization, Healthcare Facilities Accreditation Program, Joint Commission on Accreditation of Healthcare Organizations, Education for Physicians on End-of-Life Care Project (cosponsored by the American Medical Association and The Robert Wood Johnson Foundation), American Nursing Association, and the American Society of Pain Management Nurses. This white paper describes the literature and rationale in support of the American Osteopathic Association's (AOA's) position on the controversial subject of the use of placebos for pain management in terminally ill patients. The following policy statement was adopted by the AOA's House of Delegates in 2005. This statement was drafted by the association's Council on Palliative Care Issues, which at that time was called the End-of-Life Care Committee. This statement has been modified to adhere to the house style of JAOA—The Journal of the American Osteopathic Association.