Skip to main content
SpringerLink
Log in

Management of Pain in the Elderly at the End of Life

  • Review Article
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Pain is one of the symptoms most frequently encountered in elderly patients at the end of life. The management of pain in the elderly in general has been associated with undertreatment. The geriatric population has been identified as a challenging population with respect to pain management because of issues related to co-morbidities, polypharmacy and cognitive dysfunction. In the geriatric population, the assessment of pain requires measurement of pain intensity, delineation of opioid responsiveness, and clarification of the impact of pain on patients’ psychological, social, spiritual and existential domains. Effective pain management is guided by the World Health Organization (WHO) analgesic stepladder, which categorizes pain intensity according to severity and recommends analgesic agents based on their strength and works effectively in the elderly patient population. Step 1 is reserved for mild pain. Patients in this category are treated with nonopioid analgesics such as acetaminophen, or a nonsteroidal anti-inflammatory, with consideration of an adjuvant analgesic if necessary. Step 2 is reserved for patients experiencing mild to moderate pain who are already taking a nonopioid analgesic, with or without an adjuvant analgesic, but are still experiencing poor analgesic control. Step 2 agents include acetaminophen products containing hydrocodone, oxycodone, codeine and tramadol. Patients with moderate to severe pain require strong analgesics belonging to step 3 of the WHO analgesic stepladder. Step 3 opioids include morphine, hydromorphone, fentanyl, levorphanol, methadone and oxycodone. Familiarity with opioid pharmacokinetics, equi-analgesic dosing and adverse effects is necessary for the safe and effective use of these drugs. The appropriate use of adjuvant analgesics such as antiepileptic drugs, antidepressants and local anaesthetics can enhance the use of opioids, especially in cases where opioid responsiveness may be in question, such as with neuropathic pain. This paper will provide an overview of the analgesic considerations for elderly patients at the end of life.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Table I
Table II
Table III
Table IV
Table V
Table VI

Similar content being viewed by others

References

  1. Thomas JR, Von Gunten CF. Pain in terminally ill patients: guidelines for pharmacological management. CNS Drugs 2003; 17(9): 621–31

    Article  CAS  PubMed  Google Scholar 

  2. Davis MP, Srivastava M. Demographics, assessment and management of pain in the elderly. Drugs Aging 2003; 20(1): 23–57

    Article  CAS  PubMed  Google Scholar 

  3. Nordgren L, Sörensen S. Symptoms experienced in the last six months of life in patients with end-stage heart failure. Eur J Cardiovasc Nurs 2003; 2(3): 213–7

    Article  PubMed  Google Scholar 

  4. Grond S, Zech D, Schug SA, et al. Validation of World Health Organization guidelines for cancer pain relief during the last days and hours of life. J Pain Symptom Manage 1991; 6(7): 411–22

    Article  CAS  PubMed  Google Scholar 

  5. Lussier D, Huskey AG, Portenoy RK. Adjuvant analgesics in cancer pain management. Oncologist 2004; 9(5): 571–91

    Article  CAS  PubMed  Google Scholar 

  6. Serlin RC, Mendoza TR, Nakamura Y, et al. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain 1995; 61(2): 277–84

    Article  CAS  PubMed  Google Scholar 

  7. Cherny NI, Portenoy RK. Cancer pain: principles of assessment and syndromes. In: Wall PD, Melzack R, editors. Textbook of pain. 4th ed. London: Churchill Livingstone, 1999: 1017–64

    Google Scholar 

  8. Bruera E, Kim HN. Cancer pain. JAMA 2003; 290(18): 2476–9

    Article  CAS  PubMed  Google Scholar 

  9. Portenoy RK, Hagen NA. Breakthrough pain: definition, prevalence and characteristics. Pain 1990; 41(3): 273–81

    Article  CAS  PubMed  Google Scholar 

  10. Svendsen KB, Andersen S, Arnason S, et al. Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms. Eur J Pain 2005; 9(2): 195–206

    Article  PubMed  Google Scholar 

  11. Farrar JT, Cleary J, Rauck R, et al. Oral transmucosal fentanyl citrate: randomized, double-blinded, placebo-controlled trial for treatment of breakthrough pain in cancer patients. J Natl Cancer Inst 1998; 90(8): 611–6

    Article  CAS  PubMed  Google Scholar 

  12. Strang P, Strang S, Hultborn R, et al. Existential pain: an entity, a provocation, or a challenge? J Pain Symptom Manage 2004; 27(3): 241–50

    Article  PubMed  Google Scholar 

  13. Overcash J. Symptom management in the geriatric patient. Cancer Control 1998; 5 (3 Suppl. 1): 46–7

    PubMed  Google Scholar 

  14. Turk DC, Dworkin RH, Allen RR, et al. Core outcome domains for chronic pain clinical trials: IMMPACT recommendations. Pain 2003; 106(3): 337–45

    Article  PubMed  Google Scholar 

  15. Bair MJ, Robinson RL, Eckert GJ, et al. Impact of pain on depression treatment response in primary care. Psycho-som Med 2004; 66(1): 17–22

    Article  Google Scholar 

  16. Chang VT, Hwang SS, Feuerman M. Validation of the Edmonton Symptom Assessment Scale. Pain 2000; 88: 2164–71

    CAS  Google Scholar 

  17. Management of cancer pain: adults. Cancer Pain Guideline Panel. Agency for Health Care Policy and Research. Am Fam Physician 1994; 49(8): 1853–68

    Google Scholar 

  18. Fishman B, Pasternak S, Wallenstein SL, et al. The Memorial Pain Assessment Card: a valid instrument for the evaluation of cancer pain. Cancer 1987; 60(5): 1151–8

    Article  CAS  PubMed  Google Scholar 

  19. Graham C, Bond SS, Gerkovich MM, et al. Use of the McGill Pain Questionnaire in the assessment of cancer pain: replicability and consistency. Pain 1980; 8(3): 377–87

    Article  CAS  PubMed  Google Scholar 

  20. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singap 1994; 23(2): 129–38

    CAS  PubMed  Google Scholar 

  21. Ashburn MA, Lipman AG. Management of pain in the cancer patient. Anesth Analg 1993; 76(2): 402–16

    CAS  PubMed  Google Scholar 

  22. Weiner D, Peterson B, Ladd K, et al. Pain in nursing home residents: an exploration of prevalence, staff perspectives, and practical aspects of measurement. Clin J of Pain 1999; 15(2): 92–101

    Article  CAS  Google Scholar 

  23. Ezenwa MO, Ameringer S, Ward SE, et al. Racial and ethnic disparities in pain management in the United States. J Nurs Scholarsh 2006; 38(3): 225–33

    Article  PubMed  Google Scholar 

  24. Gatchel RJ, Peng YB, Peters ML, et al. The biopsychoso-cial approach to chronic pain: scientific advances and future directions. Psychol Bull 2007; 133(4): 581–624

    Article  PubMed  Google Scholar 

  25. Cutler RB, Fishbain DA, Lu Y, et al. Prediction of pain center treatment outcome for geriatric chronic pain patients. Clin J of Pain 1994; 10(1): 10–7

    Article  CAS  Google Scholar 

  26. Glock M, Friedman R, Myers P. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia: January 1985 through July 1995: 1147 citations. 2nd ed. Bethesda (MD): US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Library of Medicine, Reference Section, 1995

    Google Scholar 

  27. Mystakidou K, Tsilika E, Parpa E, et al. Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer. Arch Psychiatr Nurs 2007; 21(3): 150–61

    Article  PubMed  Google Scholar 

  28. Mercadante S. Predictive factors and opioid responsiveness in cancer pain. Eur J Cancer 1998; 34(5): 627–31

    Article  CAS  PubMed  Google Scholar 

  29. Clohisy DR, Mantyh PW. Bone cancer pain. Cancer 2003; 97(S3): 866–73

    Article  PubMed  Google Scholar 

  30. Mao J. Opioid-induced abnormal pain sensitivity: implications in clinical opioid therapy. Pain 2002 Dec; 100(3): 213–7

    Article  CAS  PubMed  Google Scholar 

  31. Mao J. Opioid-induced abnormal pain sensitivity. Curr Pain Headache Rep 2006; 10(1): 67–70

    Article  PubMed  Google Scholar 

  32. Eide PK. Wind-up and the NMDA receptor complex from a clinical perspective. Eur J Pain 2000; 4(1): 5–15

    Article  CAS  PubMed  Google Scholar 

  33. Mercadante S, Portenoy RK. Opioid poorly-responsive cancer pain. Part 2: basic mechanisms that could shift dose response for analgesia. J Pain Symptom Manage 2001; 21(3): 255–64

    Article  CAS  PubMed  Google Scholar 

  34. Mercadante S, Arcuri E, Ferrera P, et al. Alternative treatments of breakthrough pain in patients receiving spinal analgesics for cancer pain. J Pain Symptom Manage 2005; 30(5): 485–91

    Article  CAS  PubMed  Google Scholar 

  35. World Health Organization (WHO). Cancer pain relief. 2nd ed. Geneva: WHO, 1996

    Google Scholar 

  36. Bruera E, Palmer JL, Bosnjak S, et al. Methadone versus morphine as a first-line strong opioid for cancer pain: a randomized, double-blind study. J Clin Oncol 2004; 22(1): 185–92

    Article  CAS  PubMed  Google Scholar 

  37. Bellville JW, Forrest WH, Miller E, et al. Influence of age on pain relief from analgesics. JAMA 1971; 217(13): 1835–41

    Article  CAS  PubMed  Google Scholar 

  38. Gloth III FM. Pain management in older adults: prevention and treatment. J Am Geriatr Soc 2001; 49(2): 188–99

    Article  PubMed  Google Scholar 

  39. Tumer N, Scarpace PJ, Lowenthal DT. Geriatric pharmacology: basic and clinical considerations. Annu Rev Pharmacol Toxicol 1992; 32(1): 271–302

    Article  CAS  PubMed  Google Scholar 

  40. Ward SE, Goldberg N, Miller-McCauley V, et al. Patient-related barriers to management of cancer pain. Pain 1993; 52(3): 319–24

    Article  CAS  PubMed  Google Scholar 

  41. Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med 2001; 17(3): 457–vi

    Article  CAS  PubMed  Google Scholar 

  42. Lansbury G. Chronic pain management: a qualitative study of elderly people’s preferred coping strategies and barriers to management. Disabil Rehabil 2000; 22(1–2): 2–14

    Article  CAS  PubMed  Google Scholar 

  43. Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management. JAMA 1995; 274(23): 1870–3

    Article  CAS  PubMed  Google Scholar 

  44. Smith HS. Potential analgesic mechanisms of acetaminophen. Pain Physician 2009; 12(1): 269–80

    PubMed  Google Scholar 

  45. Larson AM, Polson J, Fontana RJ, et al. Acetaminophen induced acute liver failure: results of a United States multicenter, prospective study. Hepatology 2005; 42(6): 1364–72

    Article  CAS  PubMed  Google Scholar 

  46. Mercadante S, Casuccio A, Agnello A, et al. Analgesic effects of nonsteroidal anti-inflammatory drugs in cancer pain due to somatic or visceral mechanisms. J Pain Symptom Manage 1999; 17(5): 351–6

    Article  CAS  PubMed  Google Scholar 

  47. Miranda HF, Silva E, Pinardi G. Synergy between the an-tinociceptive effects of morphine and NSAIDs. Can J Physiol Pharmacol 2004; 82(5): 331–8

    Article  CAS  PubMed  Google Scholar 

  48. Joishy SK, Walsh D. The opioid-sparing effects of intravenous ketorolac as an adjuvant analgesic in cancer pain: application in bone metastases and the opioid bowel syndrome. J Pain Symptom Manage 1998; 16(5): 334–9

    Article  CAS  PubMed  Google Scholar 

  49. Mercadante S, Fulfaro F, Casuccio A. A randomised controlled study on the use of anti-inflammatory drugs in patients with cancer pain on morphine therapy: effects on dose-escalation and a pharmacoeconomic analysis. Eur J Cancer 2002; 38(10): 1358–63

    Article  CAS  PubMed  Google Scholar 

  50. Israel FJ, Parker G, Charles M, et al. Lack of benefit from paracetamol (acetaminophen) for palliative cancer patients requiring high-dose strong opioids: a randomized, double-blind, placebo-controlled, crossover trial. J Pain Symptom Manage 2010; 39(3): 548–54

    Article  CAS  PubMed  Google Scholar 

  51. Prommer E. Hydrocodone: does it have a role in palliative care? J Opioid Manag 2010; 6(4): 295–9

    Article  PubMed  Google Scholar 

  52. Leppert W, Uczak J. The role of tramadol in cancer pain treatment: a review. Support Care Cancer 2005; 13(1): 5–17

    Article  PubMed  Google Scholar 

  53. Prommer EE. Tramadol: does it have a role in cancer pain management? J Opioid Manag 2005; 1(3): 131–8

    PubMed  Google Scholar 

  54. Pedersen RS, Damkier P, Brøsen K. Enantioselective pharmacokinetics of tramadol in CYP2D6 extensive and poormetabolizers. Eur J Clin Pharmacol 2006; 62(7): 513–21

    Article  CAS  PubMed  Google Scholar 

  55. Cossmann M, Kohnen C, Langford R, et al. Tolerance and safety of tramadol use: results of international studies and data from drug surveillance [in French]. Drugs 1997; 53Suppl. 2: 50–62

    Article  PubMed  Google Scholar 

  56. Gourlay GK. Advances in opioid pharmacology. Support Care Cancer 2005; 13(3): 153–9

    Article  PubMed  Google Scholar 

  57. Rodriguez RF, Castillo JM, Castillo MP, et al. Hydro-codone/acetaminophen and tramadol chlorhydrate combination tablets for the management of chronic cancer pain: a double-blind comparative trial. Clin J of Pain 2008; 24(1): 1–4

    Article  Google Scholar 

  58. Kalso E. Oxycodone. J Pain Symptom Manage 2005; 29(5): 47–56

    Article  CAS  Google Scholar 

  59. Rodriguez RF, Castillo JM, del Pilar Castillo M, et al. Codeine/acetaminophen and hydrocodone/acetaminophen combination tablets for the management of chronic cancer pain in adults: a 23-day, prospective, double-blind, randomized, parallel-group study. Clin Ther 2007; 29(4): 581–7

    Article  CAS  PubMed  Google Scholar 

  60. Grond S, Radbruch L, Meuser T, et al. High-dose tramadol in comparison to low-dose morphine for cancer pain relief. J Pain Symptom Manage 1999; 18(3): 174–9

    Article  CAS  PubMed  Google Scholar 

  61. Omar Tawfik M, Elborolossy K, Nasr F. Tramadol hy-drochloride in the relief of cancer pain: a double blind comparison against sustained release morphine. Pain 1990; 41Suppl. 5: S377

    Article  Google Scholar 

  62. Bono AV, Cuffari S. Effectiveness and tolerance of tramadol in cancer pain: a comparative study with respect to buprenorphine. Drugs 1997; 53Suppl. 2: 40–9

    Article  PubMed  Google Scholar 

  63. Dhaliwal HS, Sloan P, Arkinstall WW, et al. Randomized evaluation of controlled-release codeine and placebo in chronic cancer pain. J Pain Symptom Manage 1995; 10(8): 612–23

    Article  CAS  PubMed  Google Scholar 

  64. Trescot AM, Datta S, Lee M, et al. Opioid pharmacology. Pain Physician 2008; 11(2 Suppl.): S133–53

    PubMed  Google Scholar 

  65. Somogyi AA, Barratt DT, Coller JK. Pharmacogenetics of opioids. Clin Pharmacol Ther 2007; 81(3): 429–44

    Article  CAS  PubMed  Google Scholar 

  66. Lötsch J. Opioid metabolites. J Pain Symptom Manage 2005; 29(5): 10–24

    Article  CAS  Google Scholar 

  67. Radbruch L, Trottenberg P, Elsner F, et al. Systematic review of the role of alternative application routes for opioid treatment for moderate to severe cancer pain: an EPCRC opioid guidelines project. Palliat Med 2011; 25(5): 578–96

    Article  PubMed  Google Scholar 

  68. Muijsers RBR, Wagstaff AJ. Transdermal fentanyl: an updated review of its pharmacological properties and therapeutic efficacy in chronic cancer pain control. Drugs 2001; 61(15): 2289–307

    Article  CAS  PubMed  Google Scholar 

  69. Vasisht N, Gever LN, Tagarro I, et al. Formulation selection and pharmacokinetic comparison of fentanyl buccal soluble film with oral transmucosal fentanyl citrate: a randomized, open-label, single-dose, crossover study. Clin Drug Investig 2009; 29(10): 647–54

    Article  CAS  PubMed  Google Scholar 

  70. Collins SL, Faura CC, Moore RA, et al. Peak plasma concentrations after oral morphine: a systematic review. J Pain Symptom Manage 1998; 16(6): 388–402

    Article  CAS  PubMed  Google Scholar 

  71. Stuart-Harris R, Joel SP, McDonald P, et al. The pharmacokinetics of morphine and morphine glucuronide metabolites after subcutaneous bolus injection and subcutaneous infusion of morphine. Br J Clin Pharmacol 2000; 49(3): 207–14

    Article  CAS  PubMed  Google Scholar 

  72. Klepstad P, Kaasa S, Skauge M, et al. Pain intensity and side effects during titration of morphine to cancer patients using a fixed schedule dose escalation. Acta Anaesthesiol Scand 2000; 44(6): 656–64

    Article  CAS  PubMed  Google Scholar 

  73. De Conno F, Ripamonti C, Fagnoni E, et al. The MER-ITO Study: a multicentre trial of the analgesic effect and tolerability of normal-release oral morphine during ‘titration phase’ in patients with cancer pain. Palliat Med 2008; 22(3): 214–21

    Article  PubMed  Google Scholar 

  74. Gatti A, Reale C, Occhioni R, et al. Standard therapy with opioids in chronic pain management: ORTIBER study. Clin Drug Investig 2009; 29Suppl. 1: 17–23

    Article  CAS  PubMed  Google Scholar 

  75. National Comprehensive Cancer Network guidelines: adult cancer pain. Version 2.2011. Fort Washington (PA): National Comprehensive Cancer Network, 2011

  76. Radbruch L, Loick G, Schulzeck S, et al. Intravenous titration with morphine for severe cancer pain: report of 28 cases. Clin J of Pain 1999; 15(3): 173–8

    Article  CAS  Google Scholar 

  77. Mercadante S, Ferrera P, Villari P, et al. Frequency, indications, outcomes, and predictive factors of opioid switching in an acute palliative care unit. J Pain Symptom Manage 2009; 37(4): 632–41

    Article  PubMed  Google Scholar 

  78. Pasternak GW. Incomplete cross tolerance and multiple mu opioid peptide receptors. Trends Pharmacol Sci 2001; 22(2): 67–70

    Article  CAS  PubMed  Google Scholar 

  79. Cherny N, Ripamonti C, Pereira J, et al. Strategies to manage the adverse effects of oral morphine: an evidence-based report. J Clin Oncol 2001; 19(9): 2542–54

    CAS  PubMed  Google Scholar 

  80. Thomas J, Karver S, Cooney GA, et al. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med 2008; 358(22): 2332–43

    Article  CAS  PubMed  Google Scholar 

  81. Peuckmann-Post V, Elsner F, Krumm N, et al. Pharmacological treatments for fatigue associated with palliative care. Cochrane Database Syst Rev 2010 Nov 10; (11): CD006788

    Google Scholar 

  82. Webster L, Andrews M, Stoddard G. Modafinil treatment of opioid induced sedation. Pain Med 2003; 4(2): 135–40

    Article  PubMed  Google Scholar 

  83. Prommer EE. Methadone for cancer pain. Palliative Care: Research and Treatment 2010; 4: 1–10

    Article  Google Scholar 

  84. Lugo RA, Satterfield KL, Kern SE. Pharmacokinetics of methadone. J Pain Palliat Care Pharmacother 2005; 19(4): 13–24

    Article  PubMed  Google Scholar 

  85. Prommer E. Opioid rotation: logical choices for pain that is poorly responsive to morphine. Prog Palliat Care 2009; 17(3): 111–6

    Article  Google Scholar 

  86. Kalso E, Tasmuth T, Neuvonen PJ. Amitriptyline effectively relieves neuropathic pain following treatment of breast cancer. Pain 1996; 64(2): 293–302

    Article  CAS  PubMed  Google Scholar 

  87. Ehrnrooth E, Grau C, Zachariae R, et al. Randomized trial of opioids versus tricyclic antidepressants for radiation-induced mucositis pain in head and neck cancer. Acta Oncol 2001; 40(6): 745–50

    Article  CAS  PubMed  Google Scholar 

  88. Mercadante S, Arcuri E, Tirelli W, et al. Amitriptyline in neuropathic cancer pain in patients on morphine therapy: a randomized placebo-controlled, double-blind crossover study. Tumori 2002; 88(3): 239–42

    CAS  PubMed  Google Scholar 

  89. Kautio AL, Haanpaa M, Saarto T, et al. Amitriptyline in the treatment of chemotherapy-induced neuropathic symptoms. J Pain Symptom Manage 2008; 35(1): 31–9

    Article  CAS  PubMed  Google Scholar 

  90. Preskorn SH, Irwin HA. Toxicity of tricyclic antidepres-sants — kinetics, mechanism, intervention: a review. J Clin Psychiatry 1982; 43(4): 151–6

    CAS  PubMed  Google Scholar 

  91. Sindrup SH, Gram LF, Brosen K, et al. The selective serotonin reuptake inhibitor paroxetine is effective in the treatment of diabetic neuropathy symptoms. Pain 1990; 42(2): 135–44

    Article  CAS  PubMed  Google Scholar 

  92. Sindrup SH, Bjerre U, Dejgaard A, et al. The selective serotonin reuptake inhibitor citalopram relieves the symptoms of diabetic neuropathy. Clin Pharmacol Ther 1992; 52(5): 547–52

    Article  CAS  PubMed  Google Scholar 

  93. Sindrup SH, Bach FW, Madsen C, et al. Venlafaxine versus imipramine in painful polyneuropathy. Neurology 2003; 60(8): 1284–9

    Article  CAS  PubMed  Google Scholar 

  94. Tasmuth T, Hartel B, Kalso E. Venlafaxine in neuropathic pain following treatment of breast cancer. Eur J Pain 2002; 6(1): 17–24

    Article  CAS  PubMed  Google Scholar 

  95. Semenchuk MR, Sherman S, Davis B. Double-blind, randomized trial of bupropion SR for the treatment of neuropathic pain. Neurology 2001; 57(9): 1583–8

    Article  CAS  PubMed  Google Scholar 

  96. Prommer EE. Tapentadol: an initial analysis. J Opioid Manag 2010; 6(3): 223–6

    Article  PubMed  Google Scholar 

  97. Heimdal K, Hirschberg H, Slettebø H, et al. High incidence of serious side effects of high-dose dexamethasone treatment in patients with epidural spinal cord compression. JNeurooncol 1992; 12(2): 141–4

    CAS  Google Scholar 

  98. Sorensen PS, Helweg-Larsen S, Mouridsen H, et al. Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial. Eur J Cancer 1994; 30(1): 22–7

    Article  Google Scholar 

  99. Loblaw DA, Wu JSY, Kirkbride P, et al. Pain flare in patients with bone metastases after palliative radiotherapy — nested randomized control trial. Support Care Cancer 2007; 15(4): 451–5

    Article  PubMed  Google Scholar 

  100. Jensen TS. Anticonvulsants in neuropathic pain: rationale and clinical evidence. Eur J Pain 2002; 6: 61–8

    Article  CAS  PubMed  Google Scholar 

  101. Caraceni A, Zecca E, Bonezzi C, et al. Gabapentin for neuropathic cancer pain: a randomized controlled trial from the Gabapentin Cancer Pain Study Group. J Clin Oncol 2004; 22(14): 2909–17

    Article  CAS  PubMed  Google Scholar 

  102. Sabers A, Gram L. Newer anticonvulsants: comparative review of drug interactions and adverse effects. Drugs 2000; 60(1): 23–33

    Article  CAS  PubMed  Google Scholar 

  103. Yajnik S, Singh GP, Singh G, et al. Phenytoin as a co-analgesic in cancer pain. J Pain Symptom Manage 1992; 7(4): 209–13

    Article  CAS  PubMed  Google Scholar 

  104. Dunteman ED. Levetiracetam as an adjunctive analgesic in neoplastic plexopathies. J Pain Palliat Care Pharmacother 2005; 19(1): 35–43

    PubMed  Google Scholar 

  105. Rao RD, Flynn PJ, Sloan JA, et al. Efficacy of lamotrigine in the management of chemotherapy-induced peripheral neuropathy: a phase 3 randomized, double-blind, placebo-controlled trial, N01C3. Cancer 2008; 112(12): 2802–8

    Article  CAS  PubMed  Google Scholar 

  106. Guay DRP. Adjunctive agents in the management of chronic pain. Pharmacotherapy 2001; 21(9): 1070–81

    Article  CAS  PubMed  Google Scholar 

  107. Bruera E, Ripamonti C, Brenneis C, et al. A randomized double-blind crossover trial of intravenous lidocaine in the treatment of neuropathic cancer pain. J Pain Symptom Manage 1992; 7(3): 138–40

    Article  CAS  PubMed  Google Scholar 

  108. Sharma S, Rajagopal MR, Palat G, et al. A phase II pilot study to evaluate use of intravenous lidocaine for opioid-refractory pain in cancer patients. J Pain Symptom Manage 2009; 37(1): 85–93

    Article  CAS  PubMed  Google Scholar 

  109. Sloan P, Basta M, Storey P, et al. Mexiletine as an adjuvant analgesic for the management of neuropathic cancer pain. Anesth Analg 1999; 89(3): 760–1

    CAS  PubMed  Google Scholar 

  110. Ripamonti C, Bruera E. Pain and symptom management in palliative care. Cancer Control 1996; 3(3): 204–13

    PubMed  Google Scholar 

  111. Wallace MS, Magnuson S, Ridgeway B. Efficacy of oral mexiletine for neuropathic pain with allodynia: a double-blind, placebo-controlled, crossover study. Reg Anesth Pain Med 2000; 25(5): 459–67

    CAS  PubMed  Google Scholar 

  112. Galer BS, Rowbotham MC, Perander J, et al. Topical lidocaine patch relieves postherpetic neuralgia more effectively than a vehicle topical patch: results of an enriched enrollment study. Pain 1999; 80(3): 533–8

    Article  CAS  PubMed  Google Scholar 

  113. Gammaitoni AR, Davis MW. Pharmacokinetics and tol-erability of lidocaine patch 5% with extended dosing. Ann Pharmacother 2002; 36(2): 236–40

    Article  CAS  PubMed  Google Scholar 

  114. Portenoy RK, McCaffery M. Adjuvant analgesics. In: Doyle D, Hanks G, Cherny N, et al., editors. Oxford textbook of palliative medicine. Oxford: Oxford University Press, 1993: 187–203

    Google Scholar 

  115. Parsons CG. NMDA receptors as targets for drug action in neuropathic pain. Eur J Pharmacol 2001; 429(1–3): 71–8

    Article  CAS  PubMed  Google Scholar 

  116. Mercadante S, Arcuri E, Tirelli W, et al. Analgesic effect of intravenous ketamine in cancer patients on morphine therapy: a randomized, controlled, double-blind, crossover, double-dose study. J Pain Symptom Manage 2000; 20(4): 246–52

    Article  CAS  PubMed  Google Scholar 

  117. Sinner B, Graf BM. Ketamine. Handb Exp Pharmacol 2008; (182): 313–33

    Google Scholar 

  118. Sikora K, Advani S, Koroltchouk V, et al. Essential drugs for cancer therapy: a World Health Organization consultation. Ann Oncol 1999; 10(4): 385–90

    Article  CAS  PubMed  Google Scholar 

  119. Schmid RL, Sandler AN, Katz J. Use and efficacy of low-dose ketamine in the management of acute postoperative pain: a review of current techniques and outcomes. Pain 1999; 82(2): 111–25

    Article  CAS  PubMed  Google Scholar 

  120. Okon T. Ketamine: an introduction for a pain and palliative medicine physician. Pain Physician 2007; 10(3): 493–500

    PubMed  Google Scholar 

  121. Johnson JR, Potts R. Cannabis-based medicines in the treatment of cancer pain: a randomised, double-blind, parallel group, placebo controlled, comparative study of the efficacy, safety and tolerability of Sativex and Tetra-nabinex in patients with cancer-related pain. Edinburgh: British Pain Society, 2005: 8–11

    Google Scholar 

  122. Johnson JR, Burnell-Nugent M, Lossignol D, et al. Multi-center, double-blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC: CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manage 2010; 39(2): 167–79

    Article  PubMed  Google Scholar 

  123. Perez J. Combined cannabinoid therapy via an oromucosal spray. Drugs Today 2006; 42(8): 495–503

    Article  CAS  PubMed  Google Scholar 

  124. Schreiber S, Getslev V, Backer MM, et al. The atypical neuroleptics clozapine and olanzapine differ regarding their antinociceptive mechanisms and potency. Pharmacol Biochem Behav 1999; 64(1): 75–80

    Article  CAS  PubMed  Google Scholar 

  125. Khojainova N, Santiago-Palma J, Kornick C, et al. Olanzapine in the management of cancer pain. J Pain Symptom Manage 2002; 23(4): 346–50

    Article  CAS  PubMed  Google Scholar 

  126. Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol 2003; 60(11): 1524–34

    Article  PubMed  Google Scholar 

  127. Prommer EE. Toxicity of bisphosphonates. J Palliat Med 2009; 12(11): 1061–5

    Article  PubMed  Google Scholar 

  128. Rosen LS, Gordon D, Kaminski M, et al. Zoledronic acid versus pamidronate in the treatment of skeletal metastases in patients with breast cancer or osteolytic lesions of multiple myeloma: a phase III, double-blind, comparative trial. Cancer J 2001; 7(5): 377–87

    CAS  PubMed  Google Scholar 

  129. Saad F, Gleason DM, Murray R, et al. A randomized, placebo-controlled trial of zoledronic acid in patients with hormone-refractory metastatic prostate carcinoma. J Natl Cancer Inst 2002; 94(19): 1458–68

    Article  CAS  PubMed  Google Scholar 

  130. Berenson JR, Lichtenstein A, Porter L, et al. Efficacy of pamidronate in reducing skeletal events in patients with advanced multiple myeloma. N Engl J Med 1996; 334(8): 488–93

    Article  CAS  PubMed  Google Scholar 

  131. Rosen LS, Gordon D, Tchekmedyian S, et al. Zoledronic acid versus placebo in the treatment of skeletal metastases in patients with lung cancer and other solid tumors: a phase III, double-blind, randomized trial — the Zoledronic Acid Lung Cancer and Other Solid Tumors Study Group. J Clin Oncol 2003; 21(16): 3150–7

    Article  CAS  PubMed  Google Scholar 

  132. Lewington VJ, McEwan AJ, Ackery DM, et al. A prospective, randomised double-blind crossover study to examine the efficacy of strontium-89 in pain palliation in patients with advanced prostate cancer metastatic to bone. Eur J Cancer Clin Oncol 1991; 27(8): 954–8

    Article  CAS  Google Scholar 

  133. Serafini AN, Houston SJ, Resche I, et al. Palliation of pain associated with metastatic bone cancer using samarium-153 lexidronam: a double-blind placebo-controlled clinical trial. J Clin Oncol 1998; 16(4): 1574–81

    CAS  PubMed  Google Scholar 

  134. Prommer EE. Established and potential therapeutic applications of octreotide in palliative care. Support Care Cancer 2008; 16(10): 1117–23

    Article  PubMed  Google Scholar 

  135. Bernard SA, Bruera E. Drug interactions in palliative care. J Clin Oncol 2000; 18(8): 1780–99

    CAS  PubMed  Google Scholar 

  136. Miguel R. Interventional treatment of cancer pain: the fourth step in the World Health Organization analgesic ladder? Cancer Control 2000; 7(2): 149–56

    CAS  PubMed  Google Scholar 

  137. Wong GY, Schroeder DR, Carns PE, et al. Effect of neu-rolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA 2004; 291(9): 1092–9

    Article  CAS  PubMed  Google Scholar 

  138. Bruera E, Brenneis C, Michaud M, et al. Use of the subcutaneous route for the administration of narcotics in patients with cancer pain. Cancer 1988; 62(2): 407–11

    Article  CAS  PubMed  Google Scholar 

  139. Ripamonti C, Zecca E, Brunelli C, et al. Rectal methadone in cancer patients with pain. Ann Oncol 1995; 6(8): 841–3

    CAS  PubMed  Google Scholar 

  140. Leow KP, Cramond T, Smith MT. Pharmacokinetics and pharmacodynamics of oxycodone when given intravenously and rectally to adult patients with cancer pain. Anesth Analg 1995; 80(2): 296–302

    CAS  PubMed  Google Scholar 

  141. De Conno F, Ripamonti C, Saita L, et al. Role of rectal route in treating cancer pain: a randomized crossover clinical trial of oral versus rectal morphine administration in opioid-naive cancer patients with pain. J Clin Oncol 1995; 13(4): 1004–8

    PubMed  Google Scholar 

  142. Weinberg DS, Inturrisi CE, Reidenberg B, et al. Sublingual absorption of selected opioid analgesics. Clin Pharmacol Ther 1988; 44(3): 335–42

    Article  CAS  PubMed  Google Scholar 

  143. Dale O, Hjortkjaer R, Kharasch ED. Nasal administration of opioids for pain management in adults. Acta Anaes-thesiol Scandinavica 2002; 46(7): 759–70

    Article  CAS  Google Scholar 

  144. Shelley K, Paech MJ. The clinical applications of intranasal opioids. Curr Drug Deliv 2008; 5(1): 55–8

    Article  CAS  PubMed  Google Scholar 

  145. Reisfield GM, Wilson GR. Rational use of sublingual opioids in palliative medicine. J Palliat Med 2007; 10(2): 465–75

    Article  PubMed  Google Scholar 

  146. Krajnik M, Zylicz Z, Finlay I, et al. Potential uses of topical opioids in palliative care-report of 6 cases. Pain 1999; 80(1–2): 121–5

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

No sources of funding were used to assist in the preparation of this article. The authors have no conflicts of interest that are directly relevant to the content of this article.

Author information

Authors and Affiliations

  1. Department of Hematology/Oncology/Palliative Care, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA

    Eric Prommer & Brandy Ficek

Authors
  1. Eric Prommer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brandy Ficek
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Eric Prommer.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Prommer, E., Ficek, B. Management of Pain in the Elderly at the End of Life. Drugs Aging 29, 285–305 (2012). https://doi.org/10.2165/11599210-000000000-00000

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/11599210-000000000-00000

Keywords

Search

Navigation