Pain management

1. Role of Pain Management and
Palliative Care
Prof . A. ADENIPEKUN
Consultant Radiation Oncologist
UNIVERSITY COLLEGE HOSPITAL
IBADAN

2. Objectives
By the end of the session, you should be able to:
1. Define the term palliative care & pain
2. Describe & explain the importance of palliative care
3. Various modalities of palliative care
4. Name the common opioid analgesics
5. Give key advantages of morphine relative to other pain medicines
6. Describe challenges that limit access to morphine
7. Understand why pain treatment is important
8. Challenge some common myths about pain treatment
2

3. DEFINITION OF PAIN
• The international Association for the study of pain defined pain as “an
unpleasant sensory and emotional experience associated with actual
or potential injury or described in terms of such damage”
• The intensity of pain varies with the degree of injury, disease or
emotional impact.
• Pain is whatever the experiencing person says it is, existing whenever
he/she says it does.

4. Palliative Care Definition
• Palliative care is the active, total care of patients and their
families by a multi-disciplinary team, at a time when patients
disease is no longer responsive to curative treatment and life
expectancy is relatively short (Twy cross 2003)
• Main objective of care giver is to improve quality of life of
patients who have a serious or life threaten diseases.

5. Introduction… contd
• Palliative care should not be confused with Terminal Care
• Palliative care may start from the time of diagnosis of a life
threatening illness and can go on for months and years
• Palliative care is not an alternative to other care but is a
complementary and essential component of total care.

6. Palliative Care Team(Multidisciplinary)
• Physicians
• Nurses
• Physiotherapists
• Occupational Therapist s
• Psychologists
• Drivers
• Cleaners
• Volunteers (Family members and Communities)

7. TYPES OF PAIN
• Acute : sudden onset
• Chronic: Lasting more than 3 months
• Nociceptive: due to stimulation of nociceptors e.g skin, bone muscle,
mucosa. Described as constant, waxing, waning, aching, cramping
• Neuropathic: Due to compression, invasion, destruction of the central
nervous system of peripheral nerves, described as burning, waxing,
localised or sometimes radiating,shooting

8. BARRIERS TO PAIN MANAGEMENT
• Inadequate assessment of pain
• Inadequate knowledge about pain and its treatment
• Concern about side effects of pain medications
• Patients and physicians attitudes, fear, misconceptions about pain.
• Misinformation about opioids tolerance and dependence issues
• Poorly accessible or unavailable pain management services
• Misguided regulations by government agencies

9. PAIN ASSESSEMENT
• Visual analogue scales: using scale of 0-10
• Verbal rating scale:
• Psychosocial assessment: A set of questionnaires help to assess factors such as
loss of independence, family problems, financial difficulties, social isolation and
fear of death.
• Detail History
• Physical examination
• Diagnostic imaging and laboratory studies are important
• Referral to other disciplines (Nutritionist, chaplain, psychologists may be
neccessary

10. TREATMENT OF PAIN
• WHO 3step analgesic ladder this refers to pain as
mild – simple drugs e.g paracetamol,Aspirin
Moderate – Paracetamol, NSAID,weak opioids
Severe---NSAID, strong opioids, anticonvulsants,
antidepresant, steroids, local anaesthetics
Strong opioids: morphine, oxycodone,fentanyl,
methadone

11. General guidelines of pain medications
• Match the drug with the pain syndrome
• Have a low threshold for prescribing opioids
• Add adjunct medications where appropriate
• Oral route should be the first choice
• Use Intravenous route for acute titration
• Monitor side effects
• Serve drug by the clock
• Differentiate between physical dependence and addiction

12. Barrier to availability of Opioids
- Government inability to maintain steady supply of opiods.
- Lack of adequate communication between Federal Medical
Stores and User Hospitals leading to Expiry of stocks.
- Not adhering to re-order stock level procedures.
- Inadequate supervision by FMOH.

13. DRUG TREATMENT
• OPIOIDS (most inportant for pain relief)
• Steroids
• Anti convulsants
• Antibiotics
• Cytotoxic chemotherapy

14. Classification of Opioids
Weak Opioid
Codeine
Dihydro-codeine
Strong Opioid
Pethidine
Morphine
Diamorphine
Tramadol

15. Characteristics of Morphine
• An Alkaloid derived from plant Opium poppy:Papaver somniferum
• Analgesic of choice for severe pain in terminally ill.
• Available in Liquid,Tablet,suppository and injection forms
• WHO step 3 analgesic
• Oral preparation often preferred in terminally ill
• Does not have ceiling effect
• Addiction does not occur with oral use

16. Prescribing Liquid morphine
Record keeping
• Keep record of the use of powder morphine, know the amount left in the store
• Keep record of the prepared liquid morphine
• Monitor the use of the liquid morphine, withdraw amount not being used by patient either
because of good pain control or death of patient.
Introducing Morphine
• In opioids Naïve patient =start with 5mg 4hourly.
• In elderly or patients with liver problem=start with 2mg 4hrly
• In patient on weak opioids eg codeine start with 5mg 4hrly.
• At Night _give double dose _To achieve pain free night, without an early morning pain
• If pain is not relieved in 24hrs increase dose by 50%,subsequent 30%

17. Side effects to watch out for
• 1) Initial Drowsiness---Resolves after 2 days
• 2) Initial Nausea and Vomiting, - 1|3 of patients.
• - Rarely occur in Africans.
• - Can be prevented with anti-emetics.
• 3) Constipation: - The REAL problem- should be anticipated.
• - Laxative Necessary except in AID with diarhoea e.g Bisacodyl
• - Paw-paw seeds as laxatives.
• 4)Urinary Retention In some patients due to anti cholinergic effects.
• 5)Twitches is a sign of over dose , usually due to organ failure in the
• terminally ill reduce dose by 50%. Or Give Midazolam to counteract the effect of morphine given
IM or Subcut

18. Disparity in access to opioids
Opioids are on almost all national essential medicines lists, but access
to them is severely limited in most low and middle-income countries,
where 85% of the world’s population consumes just 7% of the
medicinal opioids
18
Treat the Pain: based on data from the International Narcotics Control Board and WHO Cause of Death data (2012)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Population Medicinal opioids
Low and middle-income High-income

19. Access to morphine differs according to
country income level
Maximum coverage rate for deaths in pain from HIV or cancer based on
national consumption of opioid analgesics:
• High-income countries: 100%
• Middle-income countries: 62%
• Low-income countries: 19%
People in lower income countries are significantly less likely to get pain
treatment than people in higher-income countries
19
Treat the Pain: based on data from the International Narcotics Control Board and WHO Cause of Death data (2012)

20. Challenges that limit access to morphine
Although morphine is inexpensive people lack access due
to:
• Inadequate training or lack of knowledge of healthcare
providers
• Cultural misperceptions about pain
• Lack of appropriate government policies or guidelines
• Legal and regulatory restrictions
• Weak procurement systems
• Disproportionate concern about diversion, addiction, and
abuse
• Practices meant to prevent abuse of morphine that result
in limited access for those in need of pain relief
20
IASP: Treatment of pain in low-resource settings (2010)

21. PHYSICAL THERAPY FOR PAIN RELIEF
• Massage
• Ultrasound
• Hydrotherapy
• Aromatherapy
• Trans cutaneous nerve stimulation (TENS)
• Acupuncture
• Radiotherapy
• Psychological therapy e.g imagery, hypnosis, relaxation
exercise,biofeedback
• Spiritual care: counseling

22. Relieving Pain with RT
• 70%-80% present in advanced stage (? Africa, UCH data)
• 80% of advanced cancer present with pain
• Pain arising tissue and bony infiltration, compression of neighboring
normal tissue
• Direct Single fraction RT or short multiple fractions will achieve pain
control 60-70% cases ?will reduce morphine dose ?by how
much/studies
• Addition of weak opioids e.g Dihydrocodeine have been shown to
achieve pain control in 80% of bony metastasis. Quote studies-
world,Africa,Nig

23. Other Palliative care issues in common female
malignancies
• Severe cough from Pulmonary Metastasis
• Heamoptysis
• Difficulty in Breathing due to Pleural effusion
• Back pain/ paraparesis/paraplegia due to spinal mets
• Bleeding: Tumour site, PV, PR
• Fungating Wound

24. Radiation Doses in Palliation
• Heamostasis: 15Gy in 3 fractions
• Debulking/ Fungating 20 Gy in 5 fractions
• SVCO 25Gy in 6 fractions
• Spinal Cord Compresion : 30Gy in 10fr
• Bone mets 15- 25Gy in 3-6 fractions
• Bone mets (extremeties) 8-10Gy single fr
• Brain metastasis 30Gy in 10 fractions

25. Advantages of pain treatment
In low-resource countries, pain is the most common indication for
visiting a health care practitioner
Pain treatment:
• Improves compliance to curative treatment
• Extends survival for some patients
• Improves quality of life
• Improves patient – physician relationship
• Reduces unnecessary prolonged admission
IASP: Treatment of pain in low-resource settings (2010); Temel et al- NEJM (2010) 25

26. Dispelling some myths
• Myth: Children don’t feel pain
• There is no evidence that neonates or young children feel less pain than
adults
• Myth: Moderate or severe pain is uncommon
• Approximately 50% of people with advanced HIV and 80% of people with
advanced cancer will experience moderate or severe pain
• Other causes of pain include surgery, trauma, burns, myocardial infarction,
sickle cell disease, and childbirth
26
IASP: Treatment of pain in low-resource settings (2010); Children’s Palliative Care in Africa; Ensuring balance in national policies on
controlled substances: guidance for availability and accessibility of controlled medicines. World Health Organization (2011); Foley
et al. Pain Control for People with Cancer and AIDS (2006)

27. Dispelling some myths
• Myth: Opioids are dangerous
According to the World Health Organization:
• “Opioid analgesics, if prescribed in accordance with established dosage
regimens, are known to be safe and there is no need to fear accidental death
or dependence.”
• “A systematic review of research papers concludes that only 0.43% of patients
with no previous history of substance abuse treated with opioid analgesics to
relieve pain abused their medication and only 0.05% developed dependence
syndrome.”
27
World Health Organization: Ensuring Balance in National Policies on Controlled Substances: 2011

28. Dispelling some myths
• Myth: Pain relief is not affordable
• Locally produced oral morphine solution costs just
3.30 USD per week in Uganda and 5.00 USD per week in Nigeria
• Tablets or injectable opioids may be more expensive
• Myth: Morphine is only appropriate for patients at the end of life
• Morphine allows many patients who are not dying, but are limited by pain, to
live a more active life
• Pain treatment should be determined by the level and type of pain, not the
stage of disease
28
Treat the Pain Costing Data, 2014.

30. Take home messages
Morphine remains the mainstay drug for pain relief in Palliative care
• Pain assessment and treatment should be integrated into service
delivery in all departments
• Specialists in palliative care or anesthesiology can be called on for
complex cases
• Patients should be informed about pain and pain relief measures
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31. Nagode, Ese, Dalu
•Nagode, Ese, Dalu