Clinical Review

ABC of palliative care: Difficult pain problems

BMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7112.867 (Published 04 October 1997) Cite this as: BMJ 1997;315:867
  1. J Sykes,
  2. R Johnson,
  3. G W Hanks

    Introduction

    Roughly 80-90% of pain due to cancer can be relieved relatively simply with oral analgesics and adjuvant drugs in accordance with the World Health Organisation's guidelines. The remaining 10-20% can be difficult to treat.

    Useful adjuvant analgesics for neuropathic pain

    Our practice is to start with amitriptyline and add an anticonvulsant if the symptoms are not relieved or to substitute an anticonvulsant if the tricyclic is poorly tolerated. If pain is still uncontrolled at this stage, referral for a specialist palliative care opinion or to a pain clinic is advisable

    Corticosteroids (for example, dexamethasone 8 mg daily) may be used to reduce inflammation and oedema around a tumour if these are causing nerve compression

    Tricyclic antidepressants—The analgesic effect of tricyclics is independent of any antidepressant effect. Mixed reuptake inhibitors such as amitriptyline seem to be more effective analgesics than the selective serotonin reuptake inhibitors. The starting dose should be low (such as amitriptyline 10–25 mg at night) and then titrated upwards on a weekly basis until pain control improves or side effects become intolerable. An analgesic response has been found with amitriptyline within the range 25–75 mg, but, as the dose increases, so does the frequency of unwanted effects (the evidence of analgesic activity is much less strong for drugs other than amitriptyline)

    Anticonvulsants—Doses should start low and be titrated upwards. Sodium valproate (200 mg twice daily up to 1600 mg a day) is often better tolerated than carbamazepine (200 mg at night up to 400 mg twice daily)

    Antiarrhythmic drugs—These are reserved as second or third line drugs, when treatment with antidepressant or anticonvulsant, or both, has failed. Mexiletine (50-200 mg thrice daily) is usually the first choice in this class

    Corticosteroids (for example, dexamethasone 8 mg daily) may be used to reduce inflammation and oedema around a tumour if these are …

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