23- Pain

It is possible to suppress many kinds of pain for dying patients without morphine.  For us, to get morphine is not the main goal; however we do use a lot of tramadol and .

To control pain without morphine:

• For some diseases it is necessary to consider curative therapy even if we cannot hope for any improvement of the causal disease.  It is especially true for Cryptococcosis which is one of the main causes of severe pain in our ward.
• Never associate pharmacological agonists with antagonists.  That means, for instance, never use pentazocin (sosegon, fortal…) because we often also have to use anti-cough drugs using agonist derivatives.
• The contraindication of corticoids usually does not hold for dying patients (see "9-Dexamethasone") the same is true for addiction to drugs such as tramadol, benzodiazepines, etc.
• More generally, the danger of all painkillers is that they "mask" the occurrence of new diseases, which are sometime curable (Crypto…)
• If classical drugs seem to be inactive in treating pain from "afferent fiber lesions" try amitryptiline 25-75mg HS, but remember the side effects (sleepy) and/or the few days needed before effect is apparent.

Abdominal pain

Buscopan 10mg 1-2tabs 1-4x/day (or IM 20mg 3x/day) if it is cramping pain (level of pain varies cyclically over time). 
Tramadol…

If cause unknown, don't use diclofenac or NSAIDs.  It is permitted to use such drugs if cause is not digestive (gynecology, urology).  tramadol is never dangerous.

Stomachache

Cimetidine 400mg 1tab 2-3x/day, +/- aluminum mixture 15-30cc (at bedside) for pain, +/- tramadol…

(Not diclofenac, or other NSAIDs or dexamethasone please.  Be careful with prednisolone...)

Headache:

Try normal painkiller first (Paracetamol…).  If not active look carefully for a causal disease: CRYPTO?  TOXO?, TB? (See 19-Neuro) and then treat with tramadol 1-2tabs 3-4x/day, (+/- curative therapy)

Muscle-bone pain

1°- Massages, exercise, Paracetamol...

2°- Diclofenac 25mg 1-2tabs 3x/day (+ cimetidine 200mg 1tab 2x/day to prevent ulcers)

3°- Tramadol...

Tumor pain

Often due to compression/lesion of nerve by pressure from mass.

• 1- Take care in diagnosis.  For us, Tuberculosis & Abscess/Enlarged Lymph Nodes are often curable…  MAC and cancer are not…
• 2- Try to decrease volume of mass and inflammation in area with:

o        First (if not bleeding), normal anti-inflammatory (diclofenac 1 tab 3-4x/day + cimetidine 1tab 2x/day for prevention of ulcers)

o        Then: prednisolone low dose (1-6 tabs each morning).  Slowly increase the dose (6 tabs in morning 3tabs 3x in rest of day)

o        Finally: dexamethasone low to high dose

• 3- If pain still severe and tramadol seems to be ineffective, treat as pain from "afferent fiber lesions": amitryptiline 25-75mg HS, but remember the side effects (sleepy) and/or the few days needed before having any effect.