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Because they cannot describe this pain, it is often untreated or undertreated. Many people with advanced dementia experience chronic and sometimes severe pain. There is a common misperception in the community that morphine is given to hasten death when a person approaches the end of life. 3 (Empirin W Codeine)ģ,900 mg/360 mg (12 tablets) given in divided doses every 4 to 6 hoursĪcetaminophen with codeine no.The staff in the nursing home have assessed that Gran will benefit from morphine because she is in pain, but doesn’t this mean she will die more quickly? Useful in patients at risk for upper gastrointestinal tract bleedingĤ00 mg (8 tablets) given in divided doses every 6 hoursĪspirin with codeine no. Higher than average renal excretion, available over the counter High dosages not recommended for elderly patients Useful in those at risk for upper gastrointestinal tract bleeding
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High dosages not recommended for elderly patients, available over the counter Potential liver toxicity, available over the counter Methylprednisolone, 120 mg per day in divided doses Pamidronate (Aredia), 90 mg once a month, administered in an infusion over 2 to 4 hoursĬalcitonin (Calcimar), 100 IU per day administered subcutaneously or intramuscularlyīaclofen, 5 mg three times daily, with the dosage increased every third day until symptoms resolveĭexamethasone, 16 mg per day in divided doses Hydroxyzine (Atarax), 25 mg three times dailyĭiphenhydramine (Benadryl), 25 mg three times daily Lorazepam (Ativan), 0.5 mg three times dailyĭiazepam (Valium), 5 mg three times daily Methylprednisolone (Medrol), 120 mg per day in divided doses Mexiletine (Mexitil), 150 mg three times dailyĬapsaicin (Zostrix) applied to affected area three times dailyīaclofen (Lioresal), 5 mg three times daily, with the dosage increased every third day until symptoms resolveĭexamethasone (Decadron), 16 mg per day in divided doses Phenytoin (Dilantin), 100 mg three times daily Imipramine (Tofranil), 10 mg three times dailyĬarbamazepine (Tegretol), 200 mg twice dailyĭivalproex (Depakote), 125 mg once or twice daily 7 – 9Īmitriptyline (Elavil), 10 mg three times daily 8Ĭonversely, opioid dosages can be decreased by 50 to 75 percent every 24 hours without causing withdrawal symptoms. Dosages of morphine and other strong opioids can be safely increased by 50 percent every 24 hours until a satisfactory response is obtained. For most medications, dosage adjustments can be made every 24 to 48 hours. Medication dosages should be titrated promptly to achieve effective pain control. In general, only-as-needed prescribing should be avoided. (Both approaches result in a dosage of 60 mg per 24 hours.) If large amounts of breakthrough medications are required, consideration should be given to raising the dosage of the regularly scheduled analgesic. For example, if a patient is receiving 30 mg of sustained-release morphine (MS-Contin) every 12 hours, the breakthrough morphine dosage would be 10 mg administered every 4 hours. When opioids are used, the available daily breakthrough dosage should be equal to the regularly scheduled analgesic dosage. This allows attainment of a steady state of medication, which minimizes side effects and avoids periods of subtherapeutic treatment.Įpisodic or breakthrough pain should be anticipated and treated with as-needed pain relief in addition to the regularly scheduled analgesics. Patients with chronic or frequently recurring pain should receive medications around the clock according to the recommended dosing schedules.
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The choice of analgesic drug should be based on the type of pain ( Tables 1 through 4). Home visits can provide comfort and facilitate the doctor-patient relationship at the end of life. The physical, psychologic, social and spiritual needs of dying patients are best managed with a team approach. Side effects of pain medications should be anticipated and treated promptly, but good pain control should be maintained. Anticonvulsants can be especially useful in relieving neuropathic pain. Drugs such as corticosteroids, antidepressants and anticonvulsants can also help to alleviate pain. Physicians must overcome their own fears about using narcotics and allay similar fears in patients, families and communities. Starting with an appropriate assessment and following recommended guidelines on the use of analgesics, family physicians can achieve successful pain relief in nearly 90 percent of dying patients. Significant pain is common but is often undertreated despite available medications and technology.
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End-of-life care can be a challenge requiring the full range of a family physician's skills.
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