Ethical and practical issues with opioids in life-limiting illness.

Effective pain relief, especially at the end of life, is a primary ethical obligation based upon the principles of beneficence, nonmaleficence, patient autonomy, and particularly the concept of double effect. The pragmatic foundation of pain management begins with a complete assessment, which incorporates "WILDA" (words, intensity, location, duration, aggravating/alleviating factors) and considers the components of total pain: physical, emotional, social, and spiritual pain. Opioids are the pharmacologic sine qua non of pain management in life-limiting illness and should be prescribed based on the severity of pain, considering the functional and psychological significance of that severity. Numerous misunderstandings present a barrier to effective pain management. These misconceptions include the idea that opioids are highly addictive, that dependence or tolerance are forms of addiction, that respiratory depression is common with opioids, that opioids have a narrow therapeutic range, and that opioids are ineffective by mouth and cause too much nausea. In reality, opioids are the safest and most effective pain medicine for most moderate to severe pain in most patients. Aspects of basic opioid pharmacology, such as dosage, route of administration, rotation of drugs, and the avoidance of toxicity and complications, should be considered when initiating and maintaining therapy. Failure to pay attention to the basic rules can lead to errors in opioid management.