Management of pain in end‐stage renal disease patients: Short review

Abstract

Pain management in end stage renal disease (ESRD) patients is a complex and challenging task to accomplish, and effective pain and symptom control improves quality of life. Pain is prevalent in more than 50% of hemodialysis patients and up to 75% of these patients are treated ineffectively due to its poor recognition by providers. A good history for PQRST factors and intensity assessment using visual analog scale are the initial steps in the management of pain followed by involvement of palliative care, patient and family counseling, discussion of treatment options, and correction of reversible causes. First line should be conservative management such as exercise, massage, heat/cold therapy, acupuncture, meditation, distraction, music therapy, and cognitive behavioral therapy. Analgesics are introduced according to WHO guidelines (by the mouth, by the clock, by the ladder, for the individual, and attention to detail) using three-step analgesic ladder model. Neuropathic pain can be controlled by gabapentin and pregabalin. Substitution/addition of opioid analgesics are indicated if pain control is not optimal. Commonly used opioids in ESRD patients are tramadol, oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine. Methadone, fentanyl, and buprenorphine are the ideal analgesics in ESRD. However, complex pain syndrome requires multidrug analgesic regimen comprising opioids, non-opioids, and adjuvant medication, which should be individualized to the patient to achieve adequate pain control.

Pharmacokinetics of oxycodone/naloxone and its metabolites in patients with end-stage renal disease during and between haemodialysis sessions

“…Therefore, oxycodone can be dosed similarly in patients with ESRD and in patients without renal impairment, according to the severity of their pain. The study also indicates that oxycodone is a suitable opioid in patients with ESRD on haemodialysis as similarly proposed for fentanyl, buprenorphine or methadone [37]. Furthermore, due to oxycodone's low protein binding, patients with hypoalbuminaemia are unlikey to develop rebound pain during or after dialysis, as has been shown for buprenorphine [38].…”

The Assessment of Pain and Barriers to Pain Management: A Content Analysis From a National Sample of Hospice Psychosocial Assessments Completed by Social Workers

“…Non-pharmaceutical interventions (e.g., distraction, meditation, guided imagery) and behavioral interventions (e.g., help with medication adherence) are also useful social work approaches to facilitate pain relief. 35 -40…”

Acupuncture as a Treatment Within Integrative Health for Palliative Care: A Brief Narrative Review of Evidence and Recommendations

“…85(p.769) Specialist palliative care recommendations. Acupuncture is recommended for palliative care in multiple sclerosis, 87 pain control in HIV patients, 88,89 chronic destructive pulmonary disease, 90 patients with dementia, 91 end-stage renal disease, 92 and hiccups in palliative care in Holland (https:// www.pallialine.nl). The Australian organization, Therapeutic Guidelines, recommends acupuncture for hiccups and pain control in palliative care.…”