Reasonable starting point — reassess if inadequate.

Avoid metoclopramide in complete bowel obstruction.

When first-line agents have failed.

Combine drug classes rather than escalating opioids alone. Methadone is uniquely effective for mixed pain with a neuropathic component — the only long-acting opioid that can be crushed.

Opioids alone are inadequate for neuropathic pain. Adjuvants are first-line — add opioids only if adjuvants insufficient. Methadone uniquely effective for mixed nociceptive/neuropathic pain.

Multimodal approach is best. Combine a long-acting opioid for baseline with a short-acting for breakthrough. Reassess scheduled dose if using more than 3–4 breakthrough doses per day.

NSAIDs and steroids are highly effective adjuvants for bone pain — schedule around the clock, not PRN. Don't skip them.

Muscle relaxants are underused in hospice. Baclofen preferred for chronic spasticity. Avoid cyclobenzaprine and carisoprodol in elderly — sedating and anticholinergic.

Antispasmodics target smooth muscle spasm directly — more effective than opioids alone for cramping and colicky pain.

Ideal in frail patients — effective analgesia with no systemic side effects.

Consider the cause before treating. GERD and musculoskeletal chest pain are common and often mistaken for cardiac. Nitroglycerin for angina. Morphine reduces preload and pain in cardiac chest pain. PPI trial is both diagnostic and therapeutic for GERD.

Avoid morphine in significant renal impairment — M3G accumulates and causes agitation, myoclonus, and seizures — often mislabeled as terminal agitation. Fentanyl and hydromorphone are safer alternatives.

Start low, go slow. Avoid TCAs — high fall and anticholinergic risk. Acetaminophen is underused and highly effective. Gabapentin at low doses helps neuropathic pain with fewer side effects than TCAs.

Air hunger is a pain equivalent. Morphine is first-line — reduces perception of breathlessness. Do not withhold out of fear of respiratory depression in comfort-focused care.