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Pain is what many people say they fear most about dying, and pain at the end of life is consistently undertreated. Up to 75% of patients dying of cancer, heart failure, chronic obstructive pulmonary disease, AIDS, or other diseases experience pain. In the United States, the Joint Commission includes pain management standards in its reviews of health care organizations and, in 2018, it began mandating that each hospital have a designated leader in pain management.

The ratio of risk versus benefit changes in end-of-life pain management. Harms from the use of opioid analgesics, including death, eg, from respiratory depression (rare), are perhaps less of a concern in patients approaching the end of life. In all cases, clinicians must be prepared to use appropriate doses of opioids in order to relieve this distressing symptom for these patients. Typically, for ongoing cancer pain, a long-acting opioid analgesic can be given around the clock with a short-acting opioid medication as needed for “breakthrough” pain.

The US Food and Drug Administration (FDA) offers a Risk Evaluation and Management Strategy for long-acting and extended-release opioids to inform clinicians about appropriate prescribing and to promote safe use of opioids for patients who require them (https://www.fda.gov/media/83883/download). Some states have special training, licensing, and documentation requirements for opioid prescribing.

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