**Acknowledgements**

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

is complex but acts mainly as an antagonist of the NMDA receptor.

efficient analgesia [86].

**5. Invasive analgesic techniques**

is enabled by blocking the voltage sensitive Na+

**6. Non-pharmacological therapy**

intractable cancer pain [88].

It is used for treatment of severe acute and chronic pain. Its mechanism of action

Ketamine is given through IV, IM, SC, oral, rectal, nasal, transdermal, epidural, and intrathecal way. It is a safe drug, without effects on respiration at analgesic doses, and less nausea and vomiting compared to opioids [85]. It is used with success in treatment of postoperative pain, refractory neuropathic pain syndromes, and severe Hyperalgesia as well. Its use in PC is controversial and is based on few un-homogeny studies and with a variety of obtained results. Recent study examining refractory cancer pain showed that ketamine used at moderate doses provides

*Canabis* still is with limited evidence of its use. The recent controlled trials and

studies are unable to answer to the questions about its analgesic efficacy [87].

When the pain is refractory to pharmacological treatment, it is advised the use of *invasive analgesic techniques*. The use of local anesthetics provides a novel therapeutic approach in the treatment of pain. It is now established that neuraxial administration of drugs and use of neurolytic blocks are efficient in reduction of

The analgesic effect of local anesthetics (procaine, bupivacaine, and lidocaine)

and conduction of nerve impulses. It has been also shown that chemical neuromodulation produces effective pain relief. For this purpose, intrathecally can be administered as local anesthetic, opioids, and adjuvant medications (alpha-adrenergic agonists, eg, clonidine), baclofen, and ziconotide. Baclofen is a GABA-B agonist who intrathecally inhibits both monosynaptic and postsynaptic reflexes at the spinal level producing muscle relaxation useful in some neuropathic pain syndromes [89]. Neuroaxial blocks as the epidural/intrathecal application of opioids (in low-dose) and non-opioids drugs (low concentration local anesthetic 0.125–0.25%

levo-bupivacaine) increases the analgesic effects with few side effects [90].

subarachnoid space by a subcutaneously tunneled intrathecal catheter.

ment of neoplasm pain, refractory to pharmacological treatment [93].

Also, directly to the area of pain intrathecal pumps for small doses of medication can be used. The peripheral nerve blocks techniques, catheterization, and tumor infiltration prevent and reduce the bad memories of pain. The quality, duration, and safety of epidurally applied opioids have been intensively studied and compared [91]. It was suggested that sufentanil is a drug with the most promising profile [92]. Agents may be delivered via variety of catheters and ports. The implantation of a self-contained pump delivers medication at a specific rate into the

Neurolytic blocks or neurolysis of peripheral nerves or plexuses (celiac plexus or superior hypogastric plexus blocks), with phenol or alcohol, can be used for treat-

In recent years, due to the advancement of medical techniques and technology, other forms of treatment such as vertebroplasty, spinal cord stimulation, and prolo therapy are being used. The integration of the use of *interventional* medical and rehabilitative techniques improves the patients' lifestyle and helps reduce the pain. The use of surgical procedures is very rare for treatment of pain. There are some cases where surgery was used for relieving a nerve from compression, or at

channels, preventing the generation

**238**

We would like to express our gratitude for the long collaboration with the ex- Director of the Hospice "Sue Rider"in Skopje, Dr. Mira Adzic, who helped us with experiencing and empathy with the real problems of patients in a palliative care institution.
