The cause of the pain should first be assessed. A tricyclic antidepressant is appropriate for neuropathic pain due to neoplastic extension to peripheral nerves, a corticosteroid for nerve entrapment, an opioid for a liver distended with metastatic disease, a NSAID for bony secondaries.
Analgesics should be given regularly, adjusted to the patient's need to prevent pain and not only to suppress it. Suppression of existent pain requires larger doses, particularly where the pain has generated anxiety and fear. When it is certain that pain will return, it is callous to allow it to do so when the means of prevention exist.
A dose of analgesic should be left accessible to the patient, especially at night, when unnecessary suffering may result from reluctance to call a nurse or disturb a relative. In terminal illness, the question of whether or not the patient will become dependent on opioids ceases to be of importance (but see below) and the ordinary precautions against dependence — low, widely-spaced doses — need not be rigorously applied.
Control of severe pain without objectionable sedation can be achieved in palliative care by morphine with adjuvant drugs (given orally) in up to 80% of patients. Oral use preserves patients' independence as well as reducing the unpleasantness of frequent injections.
Full relief can be achieved only by attention to detail. We therefore provide an account of morphine use in this most important area of medical care.
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