Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Palliative Pain Management

3,860 views

Published on

  • DOWNLOAD THAT BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book that can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer that is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story That Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money That the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths that Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • HARVARD MEDICAL: "Weight-Loss Doubling" Trick for Women... ★★★ http://t.cn/AiYhcYmI
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • I tried Semenax and noticed results after 3 days! I had tried other products... But Semenax WORKS! ■■■ http://t.cn/AiQ0txm6
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Boost your brainpower with brain pill! find out more... ■■■ https://tinyurl.com/brainpill101
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Improve your Kidney Health Naturally, click here to find out how ■■■ http://scamcb.com/empoweredh/pdf
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Palliative Pain Management

  1. 1. Palliative Pain Management
  2. 2. Content • Pain – definition, assessment • Nociceptive and Neuropathic Pain • Types of pain in cancer • Opioids – principles and WHO ladder • Opioids – titration, relative potency, prescribing, formulations, side-effects • Opioid Induced Neurotoxicity (OIN) • Adjuvants for types of cancer pain
  3. 3. Principles used in symptom control • What causes the symptom ? – Physical – Psycho-social – Spiritual • How do we manage it ? • Treat the treatable • Symptom control • Review your management – things change!
  4. 4. Total Suffering Pain Social & Financial Spiritual Cultural Psychological Physical Symptoms Total Pain/Suffering Woodruff
  5. 5. Pain and advanced cancer • .. are not synonymous • ¼ of patients do not have pain • ¾ of patients experience pain at some stage of their illness – 1/3 of patients have 1 pain – 1/3 of patients have 2 pains – 1/3 of patients have >3 pains
  6. 6. Causes of pain in cancer patients Cancer related … • Visceral • Bone • Soft tissue infiltration • Nerve compression/infiltration • Muscle spasm • Raised intracranial pressure • Metabolic/ Endocrine
  7. 7. Causes of pain in cancer patients Treatment related … • Surgery – Surgical wound – acute / chronic – Adhesions • Radiotherapy – Acute / chronic e.g. mucositis / fibrosis • Chemotherapy – Acute / chronic e.g. mucositis / neuropathy
  8. 8. Causes of pain in cancer patients Associated factors … • Constipation • Pressure sores • Bladder spasm • Joint stiffness • Post herpetic neuralgia
  9. 9. Causes of pain in cancer patients Concurrent illnesses … • Low back Pain • Angina • Arthritis • IBS • Trauma • Other
  10. 10. Specific assessment tools • Visual analogue scales • Numeric analogue scales • Categorical scales • Body charts 0 10 Severe 3 Moderate 2 Mild 1 None 0 Visual analogue scale Categorical scale
  11. 11. What is “Total Pain”? Total Pain Physical Other symptoms Adverse Rx effects Insomnia/Chronic fatigue Psychological Anger Disfigurement Fear of pain/death Helplessness Social Family/Finance worries Loss of job/income Loss of role Abandonment/Isolation Spiritual Why me? Anger at God What is the point? Guilt
  12. 12. Other cancer problems • Social circumstances • Family communication • Patient coping - denial • Family coping • Treatment side-effects • Disease symptoms - recurrent disease • Genetics
  13. 13. SYMPTOMS IN ADVANCED CANCER 0 10 20 30 40 50 60 70 80 90 Asthenia Anorexia Pain Nausea Constipation Sedation/Confusion Dyspnea % Patients (n=275) Ref: Bruera 1992 “Why Do We Care?” Conference; Memorial Sloan-Kettering
  14. 14. Pain • Defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage • Acute pain is generally sudden in onset, temporary, and subsides of its own accord or after successful treatment of the cause • Chronic pain persists or recurs for prolonged and often indefinite periods of time
  15. 15. Pain Assessment • Measure pain levels with the patient at regular intervals. • Cause of pain should be identified and treated promptly. • Patients can describe: – location of pain – aggravating or relieving factors – intensity or severity – goals for pain control – duration, and when it occurs
  16. 16. Pain Scale Visual Analog Scale (VAS) 100mm long Simple Descriptive Pain Intensity Scale Numeric Rating Scale (NRS) No Pain No Pain No Pain Mild Pain Moderate Pain Severe Pain Worst Possible Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Possible Pain
  17. 17. Assessing pain Investigations may be useful
  18. 18. Assessing pain Investigations may be useful
  19. 19. Classification of Pain • Nociceptive pain - tissue damage (two types) • Somatic – e.g. metastatic bone pain • Visceral – e.g. liver capsule pain – e.g. colic from malignant bowel obstruction • Neuropathic - arises from nerve damage • Central [brain, spinal cord, autonomic] • Peripheral nerves – Dysesthetic (burning) – Lancinating/shooting – Sensory changes – hyperaesthesia, allodynia, numbness
  20. 20. • Somatic Pain • Arises from bone, muscle, cutaneous and connective tissue • Localised • Typically clinically described as throbbing, aching or stabbing • Visceral Pain • Arises from internal organs • Generalised / diffuse • Clinically, typically described as cramping or gnawing Nociceptive Pains
  21. 21. • Arises from neural tissue • Clinical descriptions variable • Continuous ‘burning’ • Spontaneous ‘lancinating’ or ‘electric’ • Associations • Allodynia abnormal sensations • Hyperalgesia Neuropathic Pain
  22. 22. Types of pain in cancer • Visceral pain • Neuropathic pain • Bony pain • Referred pain • Breakthrough pain
  23. 23. Visceral Pain • Results from infiltration , compression, distension or stretching of thoracic and abdominal viscera • Often poorly localised • Often referred to cutaneous sites • Can usually be well controlled and responds well to analgesics
  24. 24. Neuropathic pain • Pain caused by injury to, or disease of, the PNS or CNS • Puzzling & frustrating: – often seems to have no cause – may respond poorly to treatment – can last indefinitely – can escalate over time – often results in severe disability
  25. 25. Neuropathic pain • Most distinguishing feature: anatomical pattern of distribution, pain follows nerve distribution • Two broad classifications: –constant (often described as burning, throbbing, or stinging) –intermittent (often described as sharp, jabbing, or shooting) • Often worse at night
  26. 26. ‘Bony’ pain • Can be very painful • Cancer cells multiply inside the bone and put pressure on the nerves • Also causes bones to crumble – this exposes the nerves, and leads to more pain • Responds well to analgesics and radiotherapy
  27. 27. Referred pain • Pain from internal organs felt at a site distant from the tissue damage e.g. pancreatic cancer pain is felt in the back
  28. 28. Breakthrough pain • Transient increase in pain over ‘baseline’ • Rapid onset and severe • Frequent breakthrough pain may indicate inadequate control of ‘baseline’ pain
  29. 29. Dose for breakthrough cancer pain The breakthrough dose should be equivalent to a 4 hourly dose • i.e. - 1/6th of total daily opioid dose • Generally use the same opioid as being used for regular regimen
  30. 30. Around-the-Clock (ATC) Medication Pain Relief Threshold Persistent Pain Treating Persistent PainPainIntensity Time Theoretical Model
  31. 31. Breakthrough pain (BTP) Around-the-clock Medication Time Breakthrough Pain Theoretical Model PainIntensity
  32. 32. Increasing ATC Medication – May Increase Side Effects Around-the- clock Medication Breakthrough Pain Theoretical Model PainIntensity Time
  33. 33. Commonly used medication in palliative care patients • Analgesics • Antiemetics • Laxatives • Antispasmodics • Anticholinergics • Anticonvulsants • Antidepressants • Corticosteroids • Antibiotics • Sedatives
  34. 34. Drug complications • Allergy • Predicted pharmacological effects • Increased drug levels – Organ failure – Increasing age • BNF appendices – Organ failure • Liver impairment • Renal impairment – Drug interactions
  35. 35. Basic Principles of Opioid Analgesia The right dose of opioid is the one that achieves the best analgesia with the fewest side effects. • By the cause of the pain(s) • By the clock • By the ladder • By the mouth • For breakthrough pain • For the individual • Adjuvant therapies as needed • Prevent side effects
  36. 36. Opioid Side Effects Advise patients • Constipation – Co-prescribe laxatives e.g. Senna/Lactulose • Nausea & vomiting (30%) – Prophylactic anti-emetics e.g.. Haloperidol/Cyclizine/ Domperidone/Metoclopramide • Sedation – Reassure and monitor – Advise re driving • Dry mouth
  37. 37. Polypharmacy • Concurrent use of several different medications • Drug interactions • Increased cost • Non compliance • Adverse effects • Study GP – Use >5 medications – increased risk
  38. 38. • Polypharmacy & drug interactions • Cytochrome P450 interactions with inhibition or induction of drug biotransformation (‘bullets’ & ‘blanks’) • Terfenadine/ ketoconazole- cardiac dysrhythmias by inhibition of terfenadine metabolism • Rifampicin / phenytoin increases phenytoin clearance- reduced effect
  39. 39. World Health Organization Pain Ladder Cancer Pain Management Increasing Pain Step 1 Step 2 Step 3 Non-opioid +/- Adjuvant Opioid for mild to moderate pain +/- Non-opioid +/- Adjuvant Opioid for moderate to severe pain +/- Non-opioid +/- Adjuvant Address psychosocial and spiritual issues; consider adjuvant therapies Step 4 ?
  40. 40. Analgesics P A I N Paracetamol Codeine Dihydrocodeine Tramadol Morphine Diamorphine MILD SEVERE Simple analgesics Opioid agonists Strong opioid agonists
  41. 41. Paracetamol Active metabolite of phenacetin Mode of action: Analgesic Weak prostaglandin inhibitor Indications: Mild to moderate pain without inflammation Adverse effects: Rare at normal dosage Liver/renal toxicity in overdosage
  42. 42. Mode of Action Produce analgesia through actions at regions in the brain that contain endogenous opioid peptides Receptor Subtype Mu Delta Kappa Opioid Peptides + + AGONIST Codeine Morphine PARTIAL AGONIST Buprenorphine (+) + ± (+) (+) (+)
  43. 43. Prescribing Opioids • Weak opioids – Dose often Codeine limited by presence of paracetamol – Tramadol • Strong opioids – Morphine, oxycodone, diamorphine, fentanyl, hydromorphone, methadone, buprenorphine • Do NOT use: – Pethidine
  44. 44. Codeine/Morphine relative potency
  45. 45. Initiating Opioids: Starting Doses • Morphine 2.5-5 mg q4hr PO • Oxycodone 1-2 mg q4hr PO • Diamorphine 2.5mg q4hr SC • Fentanyl transdermal – ONLY for stable pain – 12 mcg/hr patch may be excessive in opioid naïve patients • Add breakthrough dose (4 hrly prn) • Consider smaller doses in frail, renally impaired and elderly patients
  46. 46. Pharmacokinetics of Opioids • Onset of pain relief – Oral opioids 15–30 min – SC opioids 5–10 min – IV opioids 1 min • Duration of pain relief – Short-acting oral opioids 3–5 hours – Long-acting oral opioids 8–12 hours – Fentanyl patches 72 hours – IV or SC opioids 2–4 hours
  47. 47. Short-acting Formulations (4 hour duration) • Opioid-naïve patients • Pain crises • Breakthrough cancer pain Long-acting Formulations (12 hour duration) • Reserve for stable situations Opioid Formulations
  48. 48. Routes of Opioid Administration • Preferred route – oral • When unable to swallow: SC, CSCI, IV, TD • Seldom used (only in special situations): – Sub Lingual (breakthrough pain, fentanyl) – Intraspinal (epidural or intrathecal) • Do NOT use IM
  49. 49. Titrating the Dose of Opioid Increase the dose by 25-50% if the patient is not achieving adequate pain control. Take into account number of breakthrough doses taken.
  50. 50. Opioid Myths Many patients harbor fears about opioids. • “It means the end is near” • “Opioids cause addiction” • “Opioids will lose their effectiveness over time, leaving nothing to treat severe pain ‘at the end’” • “Opioids will make me a zombie or take away my mental capacity” • “They will stop my breathing” • “They will my shorten life”
  51. 51. Common Opioid Adverse Effects Common side effects: • Constipation (requires ongoing laxatives) • Nausea – Usually resolves after a few days – Metoclopramide or cyclizine in the first few days • Sleepiness (usually resolves after a few days) Less common side effects: • Opioid neurotoxicity • Sweating, dry mouth, pruritis – very uncommon (especially with appropriate dosing) • Respiratory depression
  52. 52. Opioid Induced Neurotoxicity (OIN) • Clinical Presentation – Myoclonus, hallucinations, cognitive impairment, delirium, severe somnolence, dysaesthesia, allodynia • Mechanism unclear – Opioid metabolites – Opioids themselves • Increased risk – Renal impairment, high doses of opioids, infection (sepsis)
  53. 53. Management of Opioid Neurotoxicity (OIN) Seek advice from the Specialist Palliative Care Team Exclude other causes for symptoms. The main strategies for treatment of OIN are: – Hydration – Opioid dose reduction – Opioid switching – Change route of administration
  54. 54. Constipation – management • Pre-empt constipation by putting everyone at risk (e.g. patients on opioids) on regular aperients • Treat reversible causes e.g. give analgesia if pain on defecation, alter diet, ↑ fluid intake • Treat with regular stool softener (e.g. lactulose) ± regular bowel stimulant (e.g. senna) or a combination drug (e.g. co- danthrusate). Titrate dose against response
  55. 55. - If that is ineffective consider adding rectal measures. • if soft stools and lax rectum—try bisacodyl suppositories (0 must come into direct contact with rectum); • if hard stools—try glycerol suppositories—insert into the faeces and allow to dissolve • - If still not cleared refer to the district nurse for lubricant ± high phosphate (stimulant) enema (usually act in ~20min.) • - Once cleared leave on a regular aperient with instructions to ↑ aperients if constipation recurs. Constipation – management
  56. 56. Types of pain in cancer • Visceral pain • Neuropathic pain • Bony pain • Referred pain • Breakthrough pain
  57. 57. Adjuvants for Visceral Pain • Liver metastases or malignant bowel obstruction – Corticosteroids (Dexamethasone 2-8 mg OD or BD) – NSAIDs e.g. Diclofenac SR 75mg bd • Colic – Hyoscine Butylbromide SC (20mg)
  58. 58. Dysaesthetic pain (burning) Neuralgic pain (lancinating) Opioid and dose titration (moderate to severe pain) Gabapentin or Pregabalin or TCA TCA and Gabapentin or Pregabalin +/- lidocaine patch Corticosteroid (may be used first line in pain crisis) NMDA antagonists (ketamine) Drugs for Neuropathic Pain
  59. 59. Adjuvants for Bone Pain [1] • NSAIDs – Limited use in severe pain – Renal and gastro-intestinal side effects – Limitations of Cox-2 specific NSAIDs recently noted • Steroids – Useful in pain crises • Radiotherapy – 75% to 85% response rate (decreased pain) – Few side effects with palliative therapy – Response within 1 to 2 weeks (maximum response up to 4 weeks later) – Duration of analgesia is several months
  60. 60. Adjuvants for Bone Pain [2] • Bisphosphonates – Reduction of skeletal events (good evidence) – Management of more acute pain with parenteral infusion (some controversy) • Surgery – impending or pathological fracture
  61. 61. Key points
  62. 62. Pain Management • Nociceptive Pain – Somatic: arises from bone, muscle, cutaneous tissue and CT. localised, clinically presents as throbbing/aching/stabbing pain. – Visceral: internal organs, generalised diffuse achy pains like period pains • Neuropathic Pain – Arises from neural tissue: PNS or CNS – Can be continuous or spontaneous, descriptions vary from burning to electric – Associated with allodynia (slightest touch causes pain), hyperalgesia (exaggerated pain response) – May be disproportionate to injury (chronic) or indicate neural compression (cancer) – May respond poorly to treatment – Can last indefinitely and escalate over time – severe disability – Distinguishing feature: anatomical pattern of distribution – Constant or intermittent – burning, throbbing OR sharp stabbing, jabbing – Often worse at night – Rx: gabapentin, pregabalin, amytriptyline, paroxetine, opioids help a bit, ketamine • Visceral Pain – Arises from internal organs, is generalised or diffuse and poorly localised – Crampy/colicky pain – May respond better to anti-cholinergic/anti-spasmodics e.g. buscopan
  63. 63. Pain Management • Referred Pain – Pain from internal organs felt at a distant site from tissue damage – E.g. back pain in pancreatic cancer, shoulder tip pain in diaphragm irritation • “Bony” Pain – Can be really painful – Cancer cells multiply inside bones and put pressure on the nerves, they also cause bone to crumble which exposes the nerves  pain – Responds well to analgesics and radiotherapy – Pathological fractures and prophylactic stinting • Breakthrough Pain – Transient increase in pain over “baseline” – Rapid onset of severe pain – May indicate inadequate control of baseline pain if frequently occurring – Dose = 1/6 of daily opioid dose ( one 4hourly dose) – Same opioid as baseline medication, faster acting if possible – Careful of A/Es – If too much breakthrough being used: review analgesia and change dose
  64. 64. Pain Management • Prescribing Opioids – Weak: codeine dose often limited by paracetamol. Tramadol used but nauseating and causes delirium – Strong: morphine, oxycodone (oxycontin-baseline and oxynorm-breakthrough), diamorphine, hydromorphone, methadone (good for neuropathic pain but last line), buprenorphine – Do NOT use pethidine: useless, causes epileptic fits – Codeine is metabolised to morphine – 10g codeine = 1g morphine • E.g. 2 x 8/500 codeine = 16 codeine = 1.6 morphine
  65. 65. Pain Management • Starting Doses – Morphine: 2.5-5mg q4hr PO – Oxycodone 1-2mg q4hr PO – Diamorphine 2.5mg q4hr SC – Fentanyl transdermal patch for stable pain 12mcg/hr (=45mg oral morphine) – Add breakthrough dose: 1/6 daily dose – Smaller doses in renal impairment, old, frail, hepatic failure – Monitor A/Es for toxicity – Onset: 15-30min PO, 5-10min SC, 1min IV – Duration: short acting 3-5 hours (4hrly), long acting 8-12hrs, fentanyl patch 72hrs, IV/SC 2-4hrs – Long acting: stable pain – Short acting: breakthrough, pain crises, opioid naïve pts – CSCI: continuous sub cutaneous infusion – Do NOT use IM – Inadequate pain control: increase dose by 25-50% – A/Es: constipation (laxatives), nausea, (anti-emetics), sleepiness. OD, sweating, dry mouth, pruritis, resp depression
  66. 66. Pain Management • Opioid Induced Neurotoxicity – Presentation: myoclonus, hallucinations (flashes of light), cognitive impairment, delirium, severe somnolence, dysaethesia, allodynia – Mechanism: unsure if due to opioid metabolites or opioids themselves – Increased risk: renal impairment, high dose opioids, infection (natural opioid released by body) – RR 8+: watch – RR<8 – give naloxone slowly. Reverses A/Es as well as pain effects – Management: hydration, opioid dose reduction, opioid switching, changed route • Adjuvants for visceral Pain – Liver mets or malignant bowel obstruction: steroids, NSAIDs – Colic: hyoscine butylbromide – buscopan 20mg • Adjuvants for bone pain – NSAIDs – if not severe, careful with kidneys and liver – Steroids: good for pain crises. Not long term – Radiotherapy: 75-85% response rate within 1-2weeks, lasts several months – Bisphosphonates: reduces skeletal events, helps with pain – Surgery: stent impending or pathological fracture

×