14 Renally excreted metabolites of morphine may inhibit Renshaw cell activity in the spinal cord. The first step in combating opioid-induced agitation and myoclonus is to lower the dose of opioid, if possible. Benzodiazepines, often delivered as an infusion of midazolam or lorazepam, are also helpful in combating this untoward opioid side effect. Benzodiazepine infusions may also be useful in the treatment of restlessness, pain, and nausea. Incremental titration of these agents under medical direction by experienced IV or hospice nurses is often successful in the home setting.
Patients expect attentive care for their pain, before it becomes severe.
Use of newer opioid formulations can simplify dosing. Rotation of analgesics is often effective in treating opioid side effects. Methadone has reentered cancer pain management as an opioid with unique effects on neuropathic pain. Pain generally diminishes as death approaches, and our palliative efforts need to shift to the other concerns for bodily comfort that afflict the dying patient. Dr Anderson is medical director, HealthSpan Hospice, Minneapolis.