Pain in Advanced Illness--Getting the Tough Jobs Done

When we talk about complex pain and patients with advanced illness, there are some basics that people need to know, which is how to treat the patients with opioids and other coanalgesic medications, but the key point is that it’s a team affair, and I would ask primary care physicians not to do it alone, to think of it as a team effort. The first step is a careful assessment so that clinicians are understanding not only the physical components of the patient’s experience of pain, but also the psychological, the social, and the spiritual components. Because pain is often a total experience. It’s very much influenced as well by the family. I think with advanced illness we also need to recognize these folks are in the penalty box. They are moving towards the end of their lives and the message with every dose of medication is you’re approaching your death. And when we see people who are noncompliant, we need to ask the question what’s the psyche that’s behind that and are our plans really helping?

Another thing we need to recognize is pain management is about helping people live their lives. People with pain don’t function well, they don’t eat well, they don’t sleep well, they don’t think well, and they’ve got lousy moods. Some of them are withdrawn, some are completely dysfunctional. So, you and I as primary providers need to be monitoring the improvement of those dimensions of function. If they are getting better, that’s what we hope for. If they’re not, we’ve got to change the plan. That’s where either the pain team or the palliative care team can be super helpful to primary care providers. Many patients with advancing illness get bad neuropathic pain and they may need to use ketamine or lidocaine or methadone for their management. These are medications that most of us aren’t familiar with from our medical school training. They’re really tools where the expertise lies in either the pain management specialist or palliative care teams; when those patients then return to the community, primary care providers need to follow them closely, as with some of these agents particularly methadone, the adverse effects may come on over several days to several weeks. So, it’s about a relationship, it’s about constantly touching base with the patient and their family. It’s about making sure that the family is educated in what to look for. Do we have a change in the person’s level of cognitive function, are they becoming a little confused or are they becoming a little excited? If the family knows the things to monitor for, they can call the primary provider, and the primary provider can refer back to the specialist. It’s a partnership. It’s a team’s sport.