Pain in terminally ill patients: guidelines for pharmacological management.

Successful pharmacological treatment of pain in terminally ill patients is possible most of the time. It requires a determination of the type of pain syndrome (i.e. nociceptive, neuropathic or mixed). Complete pain assessment also requires an understanding of other dimensions of suffering that a patient may be experiencing on psychological, social and spiritual/existential levels. The World Health Organization has introduced a three-step approach to treating pain. Opioids are the mainstay of therapy for moderate to severe pain at the end of life. Familiarity with the pharmacokinetics, equianalgesic dose and adverse effects of opioids is necessary for their safe and effective use. In addition, adjuvant analgesics such as antiepileptic drugs, antidepressants and local anaesthetics are often needed to optimise pain control, especially in patients with neuropathic pain. Given the complex aetiology of pain states, combinations of classes of adjuvants may sometimes be needed for effective treatment.