The future of neuromodulation shows incredible potential and will likely demonstrate greater integration of various techniques as adjunctive therapy to already accepted standard of care management. Extensive research continues on current applications of neuromodulation such as movement disorders, while new indications are also being investigated. These new indications include depression, obsessive-compulsive disorder, impulsivity disorders, addiction, eating disorders, obesity, tinnitus, blood pressure control and traumatic brain injury. In addition, neuromodulation may have a potential role in palliative care medicine. Patients in this sector often suffer from significantly distressing symptoms that have a common basis to some of those pathologies mentioned above. If effective, neuromodulatory techniques could alleviate these symptoms and facilitate a better quality of life for the patient’s remaining time. Here, we discuss the potential roles of neuromodulation by way of deep brain stimulation (DBS), motor cortex stimulation (MCS), spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS). These various modalities are examined for refractory symptoms of dyspnea, gastrointestinal (GI) dysfunction, motor deficits, depression, delirium, mentation and sleep disturbance in palliative care patients. We review discovery of incidental amelioration of symptoms, current knowledge on mechanism of action specific to modality, analysis of results reported in literature, limitations of data, barriers to application and future research. Many of the advances in functional neurosurgery have come from unintended benefits while treating other conditions and we suspect that increasing use of neuromodulation will result in similar findings of relief for other symptoms. It is an exciting time to be involved in neuromodulation as we seek to improve quality at end of life.

Chronic fatigue syndrome and fibromyalgia are two separate but related medical conditions which are often associated with significant sleep disturbances as well as pain. The pathophysiologies of these two conditions may overlap in terms of neurotransmitters involved. Poor sleep/sleep disturbances may contribute to pain and/or other symptoms and, contrariwise, pain and/or other symptoms may contribute to poor sleep/sleep disturbances.

1 Introduction to Opioids 2 Overview of Opioid-Related Terminology 3 Diagnosis and Assessment of Pain 4 Opioid Pharmacology 5 Optimizing Pharmacologic Outcomes 5a. Drug Selection 5b. Route Selection 5c. Assessing and Managing Opioid Side Effects 5d. Opioid-Induced Hyperalgesia 5e. Principles of Opioid Rotation 5f. Individualization of Therapy 6 Opioid Therapy for Cancer Pain 7 Evidence for the Use of Long-Term Opioid Therapy in Persistent Noncancer Pain 8 Pre-Opioid Prescribing Period 9 Identifying Patients at Risk for Pain Medication Misuse 10 Potential Documentation Tools in Long-Term Opioid Therapy 11 Managing the Risk of Abuse, Addiction, and Diversion 12 Special Populations 12a. Pediatric 12b. Geriatric 12c. Palliative care 13 Patients with a History of Substance Abuse 14 Resources Appendix 1. Sample AAPM Consent for Chronic Opioid Therapy Appendix 2. Sample AAPM Agreement for Long-Term Controlled Substance Therapy for Chronic Pain Appendix 3. Numerical Opioid Side Effect (NOSE) Assessment Tool Appendix 4. Translational Analgesia Score (TAS) Appendix 5. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Opioid Treatment Guidelines

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