Assessment and Management of Pain

The management of pain associated with serious chronic illness is a core objective of palliative care. Successful therapy depends on individualization of the therapy. Management begins with a comprehensive assessment that characterizes the pain and describes it in terms of the biopsychosocial context, which includes the etiology, pathophysiology, and condition or syndrome. Nonpharmacological approaches should be considered, many of which are implemented by other interdisciplinary team members. In some cases, disease-modifying therapies may be used for analgesic purposes. The nonopioids, particularly the nonsteroidal anti-inflammatory drugs, are often adequate for initial pain management. Patients with moderate or severe pain usually are also offered an opioid, and widely accepted guidelines are available to inform safe and effective prescribing. Dose titration is usually necessary, and breakthrough pain may warrant concurrent use of fixed-schedule and “as-needed” therapy. Side effects must be anticipated and managed, and a “universal precautions” approach is prudent to mitigate the risk of abuse and addiction. If a favorable balance between analgesia and adverse effects is not realized, the patient may be poorly responsive and requires reevaluation. Opioid rotation is commonly used in this situation, as is cotreatment with one or more adjuvant analgesics, such as a glucocorticoid, antidepressant, or gabapentinoid. With guideline-based pharmacotherapy and other readily available integrative medical approaches, most patients with pain associated with serious chronic illness can obtain satisfactory relief throughout the course of their illness.