5th January 2024

Non-Opioid Medications

Neuropathic Agents

It is important to first assess the patient to ascertain if there is a treatable cause of neuropathic pain. This could include nerve compression from bone or soft tissue disease that could be managed with corticosteroids, radiotherapy, or surgery. First-line management of neuropathic pain is with either a tricyclic antidepressant, pregabalin or gabapentin.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs can be used to treat inflammatory pain from soft tissue, as well as bone pain. Examples include non-selective NSAIDs that inhibit COX-1 and COX-2, such as ibuprofen, naproxen and diclofenac, or COX-2 specific medications, such as celecoxib.

Corticosteroids

Corticosteroids include dexamethasone and methylprednisolone and can be used to manage inflammation, oedema and compression-associated pain. They are used in the management of raised intracranial pressure, bone pain, nerve compression and liver capsule pain.

It is important to be aware that steroids have a large side effect profile. They are a potential cause of new-onset agitation or delirium in the palliative patient. Some side effects, such as insomnia and increased appetite, can be used to the patient’s advantage, and steroids may be prescribed solely if a patient wishes to be more alert or to eat more.

Muscle Relaxants

Muscle spasm can be a cause of significant pain at the end of life. This can be treated with muscle relaxants such as benzodiazepines or baclofen. Non-pharmacological management, such as heat pads, massage or transcutaneous electrical nerve stimulation (TENS), may also be used.