The principles of palliative symptom management:
- Symptoms can be affected by psychosocial, spiritual and existential distress(i.e. total pain): assessment of the whole person (body, mind, spirit) contributes to good symptom management
- A person cannot come to terms with their illness and the future, if they have ongoing uncontrolled symptoms
- Medication and non-medication therapies are equally important
- Frequent reassessment and adjustment of therapy is essential to achieving best symptom control
- Communication can be therapeutic: follow the talk tips and suggestions as part of the management
BC Centre for Palliative Care Symptom Management Guidelines: detailed info and algorithms
Opioids: essential, effective with appropriate safeguards
- essential in the management of pain, dyspnea and cough in advanced disease
- evidence supports opioids in advanced disease:
Review of nine systematic reviews, (152 individual studies) examining any opioid for cancer-related pain found on average, 19 of 20 patients with cancer with moderate or severe pain who receive opioids and tolerate them, will have their pain reduced to mild or no pain within 14 days. Wiffen PJ et al. 2017 Cochrane Database Syst. Rev. doi:10.1002/14651858.CD012592.pub2
Patients with advanced, non-malignant lung diseases and severe chronic breathlessness reported a subjective beneficial effect from low dose opioids on breathlessness and continued to use opioids over many months, without serious adverse effects. Yamaguchi et al. 2023 JPSM doi: 10.1016/j.jpainsymman.2022.12.146
Regular, low-dose, oral sustained-release morphine for 4 weeks improved disease-specific health status in patients with COPD, without affecting PaCO2 or causing serious adverse effects. The worst breathlessness improved in participants with mMRC grades 3 to 4. Verberkt CA et al. 2020 JAMA Intern Med. doi:10.1001/jamainternmed.2020.3134
Safeguards: Every patient who needs opioids should have an assessment for risk of opioid use disorder, and if indicated, mitigate risk through prescribing opioids with less risk of abuse (buprenorphine and methadone) and use dispensing strategies that regulate access to opioids. Educate patients/caregivers on safe storage and disposal. Urine drug screening can be used for those with moderate-high risk of SUD or on clinical judgment.