- Pain is a complex symptom and requires consideration of many factors for diagnosis and management. This guidance will focus on chronic pain (>3 months).
- A separate algorithm is provided for pain at end-of-life (last days/weeks of life).
- Separate tips are provided for acute pain management in the hospital setting.
- A thorough assessment of pain requires the following three things:
- Quantify pain and its impact using a standardized pain assessment tool
- Consider psychosocial contributors to pain and look for co-existing mental health conditions
- Addiction risk assessment
- Set realistic expectations for pain relief, in chronic pain focusing on function and goals rather than complete resolution. In general, the most that can be expected from outpatient drug treatment for chronic pain is a 30-50% reduction in intensity. Prepare the patient that the medication will be discontinued if desired effect is not achieved.
- Consider non-pharmacological therapies in all patients
- Consider the type of pain when prescribing pharmacological therapies
- Opioids are important agents in the correct setting. They should be used with caution in cirrhosis as they can worsen hepatic encephalopathy and increase risk of falls. If needed for pain management, adjust doses and dosing interval to the degree of hepatic dysfunction
- Regularly reassess the pain after initiation of pharmacological therapy to determine need for ongoing therapy
- At end-of-life, the risk-benefit ratio of pharmacological therapy may change and patients may be more accepting of sedation.
Is the pain acute with an identifiable non-cirrhosis or cirrhosis related acute cause that can be treated (e.g. a hip fracture after a fall, spontaneous bacterial peritonitis, increasing ascites contributing to abdominal distension). Treat the cause. This guidance statement does not apply to acute pain.
Is the pain chronic (present for >3 months). Consider the differential diagnosis. Modify what is modifiable if this is in keeping with the patient’s goals of care.
Pain is a complex multidimensional experience with biopsychosocial inputs. Depending upon the situation, assess the following three things as part of a thorough pain assessment:
Consider Non-pharmacological therapies
Consider non-pharmacological management in all patients in addition to pharmacological therapies.
Analgesics and other drugs are only a partial solution to the management of pain in cirrhosis (see Chronic Pain Tips).
It is important to consider the type of pain the patient is experiencing – main consideration:
Nociceptive (somatic/visceral pain) versus Neuropathic (nervous system pain,“burning/electrical”)
- Reassess pain at least monthly using the PEG, ESAS-r or the Follow-up Pain Assessment Tool to determine if there is benefit to current medication.
- If the pain is not responding as expected, go back to your differential diagnosis, re-assess for non-physical contributors to pain and review expectations for pain relief.
- Pain adequately controlled – Continue to reassess monthly
- Pain somewhat controlled but inadequate – Continue first line medication and add second line medication
- Pain not controlled (no benefit) – Stop first-line medication and start second line medication
- The dose of medications may need to be adjusted with deteriorating liver function.
- Most medications targeting neuropathic pain are not available as injectables when subcutaneous route needed (eg. gabapentin). A switch to opioid medication will likely be necessary.
- Given the focus on comfort, CNS side effects are often not as critical for patients. Good discussions are important. Faster titration of medications may result in more CNS depressant effects, which may be aligned with patient goals.
- Patients usually require subcutaneous medications at the end of life when they lose the ability to swallow.
- A history of substance use may affect the dosing of medications required at the end-of-life and may make the patient and family more reluctant to use opioids. Specialist consultation may be required.
This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.
Authors (Alphabetical): Amanda Brisebois, Sarah Burton-Macleod, Ingrid DeKock , Martin Labrie, Noush Mirhosseini, Mino Mitri, Kinjal Patel, Saifee Rashiq, Aynharan Sinnarajah, Puneeta Tandon
Thank you to pharmacists Omer Ghutmy and Meghan Mior for their help with reviewing these pages.
- General approach to pain: Chronic Pain Tips
- Substance use: https://crismprairies.ca/wp-content/uploads/2020/02/Guidance-Document-FINAL.pdf
- Fraser Health Symptom tools: https://www.fraserhealth.ca/-/media/Project/FraserHealth/FraserHealth/Health-Professionals/Professionals-Resources/Hospice-palliative-care/SymptomAssessmentRevised_Sept09.pdf
- Excellent reference for opioid prescribing for chronic non-cancer pain – Busse JW et al. DOI: https://doi.org/10.1503/cmaj.170363
- Alcohol use disorder: AUDIT-C (3 questions)
- Drug misuse screening: DAST-10 (10 questions)
- Opioid Risk Tool-revised
- Davison SN on behalf of the Kidney Supportive Care Research Group. Conservative Kidney Management Pathway; Available from: https//:www.CKMcare.com.
- British Association for the Study of the Liver. Clinical Guideline. Symptom Control and End-of-Life care in adults with Advanced Liver Disease. Version 1.0.
- Bosilkovska M, Walder B, Besson M, Daali Y, Desmeules J. Analgesics in patients with hepatic impairment: pharmacology and clinical implications. Drugs. 2012 Aug 20;72(12):1645-69. doi: 10.2165/11635500-000000000-00000. PMID: 22867045.
- Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, Agoritsas T, Akl EA, Carrasco-Labra A, Cooper L, Cull C, da Costa BR, Frank JW, Grant G, Iorio A, Persaud N, Stern S, Tugwell P, Vandvik PO, Guyatt GH. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666. doi: 10.1503/cmaj.170363. PMID: 28483845; PMCID: PMC5422149.
- Chandok N, Watt KD. Pain management in the cirrhotic patient: the clinical challenge. Mayo Clin Proc. 2010 May;85(5):451-8. doi: 10.4065/mcp.2009.0534. Epub 2010 Mar 31. PMID: 20357277; PMCID: PMC2861975.
- Imani F, Motavaf M, Safari S, Alavian SM. The therapeutic use of analgesics in patients with liver cirrhosis: a literature review and evidence-based recommendations. Hepat Mon. 2014 Oct 11;14(10):e23539. doi: 10.5812/hepatmon.23539. PMID: 25477978; PMCID: PMC4250965.
- Klinge M, Coppler T, Liebschutz JM, Dugum M, Wassan A, DiMartini A, Rogal S. The assessment and management of pain in cirrhosis. Curr Hepatol Rep. 2018 Mar;17(1):42-51. doi: 10.1007/s11901-018-0389-7. Epub 2018 Feb 22. PMID: 29552453; PMCID: PMC5849403.
- Krebs EE, Lorenz KA, Bair MJ, Damush TM et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. Journal of general internal medicine 2009 Jun 1;24 (6):733-8. PMID 19418100.
- Lewis JH, Stine JG. Review article: prescribing medications in patients with cirrhosis – a practical guide. Aliment Pharmacol Ther. 2013 Jun;37(12):1132-56. doi: 10.1111/apt.12324. Epub 2013 May 3. PMID: 23638982.
- Moulin D, Boulanger A, Clark AJ, Clarke H, Dao T, Finley GA, Furlan A, Gilron I, Gordon A, Morley-Forster PK, Sessle BJ, Squire P, Stinson J, Taenzer P, Velly A, Ware MA, Weinberg EL, Williamson OD; Canadian Pain Society. Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society. Pain Res Manag. 2014 Nov-Dec;19(6):328-35. doi: 10.1155/2014/754693. PMID: 25479151; PMCID: PMC4273712.
- Murphy EJ. Acute pain management pharmacology for the patient with concurrent renal or hepatic disease. Anaesth Intensive Care. 2005 Jun;33(3):311-22. doi: 10.1177/0310057X0503300306. PMID: 15973913.
- Rakoski M, Goyal P, Spencer-Safier M, Weissman J, Mohr G, Volk M. Pain management in patients with cirrhosis. Clin Liver Dis (Hoboken). 2018 Jul 26;11(6):135-140. doi: 10.1002/cld.711. PMID: 30992804; PMCID: PMC6385960.
- Rogal SS, Winger D, Bielefeldt K, Szigethy E. Pain and opioid use in chronic liver disease. Dig Dis Sci. 2013 Oct;58(10):2976-85. doi: 10.1007/s10620-013-2638-5. Epub 2013 Mar 20. PMID: 23512406; PMCID: PMC3751995.
- Schweighardt AE, Juba KM. A Systematic Review of the Evidence Behind Use of Reduced Doses of Acetaminophen in Chronic Liver Disease. J Pain Palliat Care Pharmacother. 2018 Dec;32(4):226-239. doi: 10.1080/15360288.2019.1611692. Epub 2019 Jun 17. PMID: 31206302.