1. The Mary Stevens Hospice Stourbridge
Lucy Martin - Medical Director
(BCVTS 1997 – 2000!)

3. VTS March 4th 2010
1.30 Session on Palliative Care and Basics of Pain Control, plus discussion and questions
2.45 Coffee / Tea
3.00 Case discussion 1 & feedback
3.45 Case discussion 2 & feedback
4.30 Plenary and close

4. What is Palliative Care?

5. WHO Definition
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

6. provides relief from pain and other distressing symptoms
affirms life and regards dying as a normal process
intends neither to hasten or postpone death
integrates the psychological and spiritual aspects of patient care
offers a support system to help patients live as actively as possible until death
offers a support system to help the family cope during the patient's illness and in their own bereavement

7. uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated
will enhance quality of life, and may also positively influence the course of an illness
is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

8. Who provides Palliative Care?

9. Generalist Specialist GPs, District Nurses, Hospitals
Providing day-to-day care in hospital or patients home
Specialist
Palliative Care Teams based in hospices, hospitals, community
Multidisciplinary – Core members are doctors & nurses, AHPs
In-patient and Day care facilities, hospice at home
Ongoing advice and support in any setting
Bereavement support
Education and training for specialists and generalists

10. Day Unit 1993, Residential Unit 1999
Day care since 1993, and residential since 1999 Referral

11. Specialist Palliative Care in Dudley
Hospice in-patient care / day care
Mary Stevens covers the whole Dudley borough
Hospital in-patient care
no dedicated hospital beds
0.4 WTE consultant – out pt and consultation
hospital palliative care team & MDT meeting
Community Service
Macmillan CNS and OT / Physio team
Palliative Care end of life team

12. What you know about pain management? What do you feel confident about?
What makes you nervous?

13. WHO ladder / lift
Cancer and non-cancer chronic pain
Dudley Pain Management Guidelines

14. Principles of analgesic use
By the mouth
By the clock
By the ladder
Refers to WHO analgesic ladder
Treatment should be individualised
Use adjuvants
Drugs for specific situations e.g. Neuropathy
Drugs to control side effects
Psychotropics
Twycross, R ‘Introducing Palliative Care’, ‘Symptom management of advanced cancer’

15. Titration and choice of opioid
Titration and choice of opioid. Rationale for not choosing several opioids at the same time. Compare and contrast the different strong opioids. The rise and rise of the transdermal route.

16. Strong opioids Should be given according to need and response
Should not be given according to prognosis
Administration still surrounded by concern

17. Little clinically significant respiratory depression, tolerance not a problem, dependence does not occur
Naloxone – very rare
Patients generally have been receiving weak opiates first
Dose gets titrated – ‘start low, go slow’
Pain is an antagonist to central depressant effects of strong opiates
Therapeutic dose vs. toxic / lethal dose

18. Opioids in the well person (or How I did it by H. Shipman)

19. Opioids in Cancer Pain (and probably non-cancer pain too)

20. Morphine Pros Cons 200+ years of experience Cheap
4 formulations – IR elixir and tablet, SR liquid and tablet / capsule
Flexibility in dosing, multiple strengths available, flexible routes
Predictable titration schedule
Metabolites accumulate in brain and CSF if renal dysfunction
20 – 30 % population do not tolerate

21. Equivalent Doses Comfortable Dose for Rx Equivalent 24hr Morphine Dose
Codeine 60mg qds p.o.
Dihydrocodeine 60mg qds p.o.
Pethidine 50mg qds p.o.
Tramadol 100mg qds p.o.
Fentanyl 25mcg t.d.
Diamorphine 2.5mg s.c. every 30 mins
Morphine 25mg
Morphine mg
Morphine 60mg
Morphine 7.5mg p.o. every 30 mins

22. Titrating in the community
Easiest method is the 4-hourly plus rescue
Calculate current morphine equivalent / 24hr
+/- make allowance for uncontrolled pain
Divide by 6
4 hourly dose / rescue dose
2 – 3 days record
Review, then divide and convert to sustained release prep, plus rescue (1/6th of total daily dose)

23. Increasing doses of opioid
Gradual escalation of doses if pain control inadequate
Dose escalations of less than 30 – 50% are unlikely to have much effect
Experience shows 30 – 50% dose increases are safe
Absolute dose is immaterial as long as balance between analgesia / side effects
Less is known about titration for dyspnea

24. Why / when to switch opioid
Intolerable side effects
Itching, neurotoxicity, that persist despite appropriate intervention
Lack of desired analgesic effect
Even with rapidly escalating doses
Moderate or severe renal disease
Egfr <60 ??
Alternative route is required
Unstable pain on a patch
Patient’s personal choice / opiophobia

25. Diamorphine Pros Cons Cheap
May work via receptors other than µ - explaining the apparent differences with morphine
More soluble / lipophilic than morphine – parenteral use /small volumes
Quicker action, less vomiting
Not useful orally
More sedating than morphine
Fear / preconceptions of patients and HCPs

26. Oxycodone Pros Cons Potent drug orally
Flexibility in SR dose formulations
Effective levels within 1 hour – good for titration
Rectal formulation
Metabolites not part of the analgesic picture
Possibility of neuropathic effect
Differing views in different countries – USA see it as a step 2 drug
Common drug of abuse in USA

27. Hydromorphone (palladone)
Pros
Cons
Multiple routes of admin – oral, parenteral, rectal and intraspinal
Very soluble – good for subcut use
Oral dosing complicated and oral breakthrough dose multiple capsules
Difficulty predicting dose equivalency with morphine

28. Fentanyl & alfentanil Pros Cons
Transdermal delivery due to lipophilic nature
Intravenous – rapid onset of action
Buccal / sublingual / intranasal immediate release formulation
Convenience / compliance
Possibly less constipation
Delay of effective analgesia hrs initially
Poor dosing flexibility
Uncertainty with BMI
Cost
Contraindication in uncontrolled pain due to titration period
Patch adhesion problems

29. Methadone Pros Cons Potent orally
Useful in pain with neurological components
Unpredictable accumulation / plasma concentration rises over long periods – unpredictable side effects
Steady state ~ 1 week
Not really practical in community setting

30. Please don’t forget Constipation Nausea senna/ lactulose movicol
co-danthrusate / co-danthramer
Nausea
metoclopramide / domperidone
haloperidol

31. Where to look for information?
Twycross books are the ‘bibles’
Palliative Care Formulary – 3rd Edition
Symptom management of advanced cancer - 4th Edition
Introducing Palliative Care
Palliativedrugs.com – online version of PCF
More detail
Oxford Textbook of Palliative Medicine
West Midlands pain handbook