1. Dr Amanda Landers Community Palliative Medicine Specialist

2.  65 year old man  Diagnosed with metastatic melanoma to axillary nodes and lung  Presents with pain under the arm radiating down onto the anterior chest wall

3.  Physiological  Poor wound healing, weakness, muscle breakdown  Immobilisation, increased risk of DVT/PE  Splinted breathing, increased risk of chest infection  Decreased gastric motility  Tachycardia and hypertension

4.  Psychological  Anxiety  Depression  Insomnia  Existential suffering which may lead to thoughts of euthanasia

5.  Immunological  Decreased natural killer cell counts  ? Other effects on the immune system

6.  Impending death  Decreased enjoyment and quality of life  Disability  Suffering long-term  Challenges to dignity  Burden to others

7.  Man started on paracetamol  1gm QID  Discussion on how this must be taken at breakfast, lunch, dinner and before bed  Strongly encouraged to take regularly

8.  paracetamol licensed by FDA 1950s  dose 500mg – 1g 4 to 6 hourly for all  maximum 4g in 24 hours for all

10.  60kg, frail 84 year old woman1g QDS  106kg, 30 year old 1g QDS  70kg, 65 year old man1g QDS

11. maximum 4g in 24 hours

12.  fit young 18 years to 30 years  fit elderly > 65 years  frail elderly> 65 years (+CVA or hospitalised)

13.  fit young 18 years to 30 years  CL100%  fit elderly > 65 years  CL70-80%  frail elderly> 65 years  CL50-55% (+CVA or hospitalised)

14. Maybe  non frail elderly  1g TDS  frail elderly  1g BD What about the 30 to 65 year olds?

15.  Man admitted to hospital with worsening chest wall pain  Oncology ward full so placed on an ‘outlying’ ward

16.  Background: do differences exist in the management of cancer-related pain in patients admitted to oncology and non-oncology settings.  Patients and methods: 48 Italian hospitals, 819 patients receiving analgesic therapy for cancer-related pain.

17.  Results: non-opioids more frequently in non- oncology units (19.6% versus 7.0%; P < 0.0001)  strong opioids are more frequently used in the oncology units (69.5% versus 51.9%; P < 0.0001).  inadequate therapy was lower in oncology compared with non-oncology units  Conclusion: Oncology wards provide the most adequate standard of analgesic therapy for cancer-related pain.

18.  Man started on morphine regularly  Switched to long-acting formulation  GP mentions fentanyl patches to him in the community

19.  Fentanyl  Oxycodone  Methadone  (Hydromorphone)  (Sufentanil)  (Combination drugs)

20.  Short acting semi synthetic opioid  Duration of action IV 30 to 60 mins  “Clean” drug: Fewer CNS and GI side effects  Routes : subcutaneous, transdermal, buccal sublingual, intrathecal  Transdermal Fentanyl patches ( Durogesic ) 12, 25, 50, 75, 100mcg/hr strengths

21.  No hot water bottles on the patch or spa baths- above 40C they leach medication  If skin irritated, use steroid inhaler on skin first  After patch removed, medication still under the skin for 12-18 hours  May need to be changed every 2 days in minority of patients

22.  Semi-synthetic opioid similar to morphine  More potent than morphine on mg to mg basis  1 mg oxycodone = 2 mg morphine  Safe to use in mild renal impairment  Clinically less CNS and GI side effects (not proven)  Oral and parenteral formulations only  Immediate and slow release preparations

23. Synthetic opioid; NMDA activity Oral to parenteral conversion usually 1:1 Still much confusion and controversy about pharmacokinetics; t1/2 varies from 12-150hrs! very potent and small doses should be prescribed “ Start low, go slow”. ?initiate in hospital setting

24.  Man seen at home with severe neuropathic pain around the chest wall  Was advised to take morphine elixir Q2H prn and he has had 5 breakthrough doses  Sleepy, hallucinating, ‘twitchy’  Still in pain What now?

25.  Indications  Most common reason is inadequate pain relief with toxicity  Cost  Compliance  Diversion concerns  Rationale  Incomplete cross-tolerance  Differing genetic backgrounds  Interdividual difference eg, GFR

27.  Man rotated onto methadone in the hospice  Neuropathic element to pain  Co-analgesics also started

28.  defined as “pain initiated or caused by a primary lesion or dysfunction in the nervous system”  diverse set of syndromes  changes may occur in the peripheral, central, and autonomic nervous system, and each can contribute to the development of chronic neuropathic pain.

29.  Brachial plexus neuropathies  Chemotherapy-induced neuropathy  Cisplatin  Oxaliplatin  Paclitaxel  Thalidomide  Vincristine  Vinblastine  Postherpetic neuropathy  Post-radiation plexopathies  Surgical neuropathies  Phantom pain  Post-mastectomy syndrome  Post-thoracotomy syndrome

30.  Non-opioids  Limited usefulness but may be worth a trial  Opioids  Co-analgesics  Steroids  Anti-convulsants  Tricyclic antidepressants  Systemic local anaesthetics  Benzodiazepines

31.  Used for nerve pain and depression  Common side effects  Dry mouth  Blurred vision  Urinary retention  Drowsiness  Lowers seizure threshold

32.  Used for nerve pain  Common side effects  Easy bruising  dizziness  ataxia  headache  twitching  peripheral oedema

33.  Corticosteroid  Used for raised intracranial pressure, nausea/vomiting, inflammation in a bowel obstruction, liver capsule pain with metastatic disease, appetite stimulation, fatigue  Commonly causes insomnia  Contraindicated in infections and GI bleeds

34.  Used as an anti-epileptic  In palliative care it is useful for nerve pain, anxiety, agitation, dypsnoea, hiccups  Common adverse effects- fatigue, drowsiness  Very potent, long-acting and its use should be closely monitored

35.  SC lignocaine  Affects sodium channels  Contraindicated in hepatic dysfunction and severe cardiac rhythm disturbances

36.  Discharged on 25mg nortriptylline, opioid and 300mg TDS gabapentin  Recommended to GP that titration of gabapentin next step in pain management  Close follow up in community