Presentation on theme: "Pain Management In Palliative Care"— Presentation transcript:
1Pain Management In Palliative Care Mike Harlos MD, CCFP, FCFPProfessor and Section Head, Palliative Medicine, University of ManitobaMedical Director, WRHA Palliative CareMedical Director, Pediatric Symptom Management Service
2PainAn unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.International Association for the Study of Pain
3Clinical Terms For The Sensory Disturbances Associated With Pain Dysesthesia – An unpleasant abnormal sensation, whether spontaneous or evoked.Allodynia – Pain due to a stimulus which does not normally provoke pain, such as pain caused by light touch to the skinHyperalgesia – An increased response to a stimulus which is normally painfulHyperesthesia - Increased sensitivity to stimulation, excluding the special senses. Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms should be used wherever they are applicable.
4Approach To Pain Control in Palliative Care Thorough assessment by skilled and knowledgeable clinicianHistoryPhysical ExaminationPause here - discuss with patient/family the goals of care, hopes, expectations, anticipated course of illness. This will influence consideration of investigations and interventionsInvestigations – X-Ray, CT, MRI, etc - if they will affect approach to careTreatments – pharmacological and non-pharmacological; interventional analgesia (e.g.. Spinal)Ongoing reassessment and review of options, goals, expectations, etc.
5Sympathetic Maintained TYPES OF PAINNOCICEPTIVENEUROPATHICSomaticbones, jointsconnective tissuesmusclesDeafferentationSympathetic MaintainedPeripheralVisceralOrgans – heart, liver, pancreas, gut, etc.
6Somatic Pain Aching, often constant May be dull or sharp Often worse with movementWell localizedEg/Bone & soft tissuechest wall
7Special Considerations in Bone Pain Spinal cord compression in vertebral mets:Pain = earliest featureRisk of pathological fractureIndications for prophylactic surgery in large, weight-bearing bonesCortical LesionsDestruction of > 50% of the cortical widthAxial length of lesion > diameter of the bone > 2 – 3 cm lesionMedullary lesionsLesion > 50% of the medullaPain unrelieved by radiotherapy
8Visceral Pain Constant or crampy Aching Poorly localized Referred Eg/ CA pancreasLiver capsule distensionBowel obstruction
9FEATURES OF NEUROPATHIC PAIN COMPONENTDESCRIPTORSEXAMPLESSteady, DysestheticBurning, TinglingConstant, AchingSqueezing, ItchingAllodyniaHypersthesiaDiabetic neuropathyPost-herpetic neuropathyParoxysmal, NeuralgicStabbingShock-like, electricShootingLancinatingtrigeminal neuralgiamay be a component of any neuropathic pain
14Medication(s) Taken Dose Route Frequency Duration Efficacy Adverse effects
15Physical Exam In Pain Assessment Inspection / Observation “You can observe a lot just by watching” Yogi BerraOverall impression… the “gestalt”?Facial expression: Grimacing; furrowed brow; appears anxious; flat affectBody position and spontaneous movement: there may be positioning to protect painful areas, limited movement due to painDiaphoresis – can be caused by painAreas of redness, swellingAtrophied musclesGaitMyoclonus – possibly indicating opioid-induced neurotoxicity
16Physical Exam In Pain Assessment Palpation Localized tenderness to pressure or percussionFullness / massInduration / warmth
17Physical Exam In Pain Assessment Neurological Examination Important in evaluating pain, due to the possibility of spinal cord compression, and nerve root or peripheral nerve lesionsSensory examinationAreas of numbness / decreased sensationAreas of increased sensitivity, such as allodynia or hyperalgesiaMotor (strength) exam - caution if bony metastases (may fracture)Deep tendon reflexes – intensity, symmetryHyperreflexia and clonus: possible upper motor neuron lesion, such as spinal cord compression or cerebral metastases.Hyoporeflexia - possible lower motor neuron impairment, including lesions of the cauda equina of the spinal cord or leptomeningeal metastases.Sacral reflexes – diminished rectal tone and absent anal reflexes may indicate cauda equina involvement of by tumour
18Physical Exam In Pain Assessment Other Exam Considerations Further areas of focus of the physical examination are determined by the clinical presentation.Eg: evaluation of pleuritic chest pain would involve a detailed respiratory and chest wall examination.
22STRONG OPIOIDS most commonly use: morphine Hydromorphone (Dilaudid ®) transdermal fentanyl (Duragesic®)oxycodoneMethadoneDO NOT use meperidine (Demerolâ) long-termactive metabolite normeperidine ® seizures
23INCOMPLETE CROSS-TOLERANCE OPIOIDS andINCOMPLETE CROSS-TOLERANCEconversion tables assume that tolerance to a specific opioid is fully “crossed over” to other opioids.cross-tolerance unpredictable, especially in:high doseslong-term usedivide calculated dose in ½ and titrate
24Approximate Equipotency with Morphine (Morphine:Drug) Hydromorphone5:1Oxycodone1.5:1 to 2:1Codeine1:12MethadoneDaily Morphine Dose30 – 90 mg3.7:190 – 300 mg7.75:1> 300 mg12.75:1Fentanyl80:1 to 100:1 (for subcutaneous dosing of each)NB: Does not consider incomplete cross-tolerance
25TITRATING OPIOIDS dose increase depends on the situation dose by %EXAMPLE: (doses in mg q4h)
30TOLERANCEA normal physiological phenomenon in which increasing doses are required to produce the same effectInturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
31PHYSICAL DEPENDENCEA normal physiological phenomenon in which a withdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administeredInturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
32PSYCHOLOGICAL DEPENDENCE and ADDICTIONA pattern of drug use characterized by a continued craving for an opioid which is manifest as compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drugInturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
33po / sublingual / rectal routes SQ / IV / IM routes Changing Route Of AdministrationIn Chronic Opioid Dosingpo / sublingual / rectal routesSQ / IV / IM routesreduce by ½
34Using Opioids for Breakthrough Pain Patient must feel in control, empoweredUse aggressive dose and intervalPatient Taking Short-Acting Opioids:% of the q4h dose, given q1h prnPatient Taking Long-Acting Opioids:% of total daily dose given, q1h prnwith short-acting opioid preparation
35Opioid Side Effects Constipation – need proactive laxative use Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol)Urinary retentionItch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great successDry mouthRespiratory depression – uncommon when titrated in response to symptomDrug interactionsNeurotoxicity (OIN): delirium, myoclonus ® seizures
37Misinterpreted as Pain Misinterpreted as Disease-Related Pain Spectrum of Opioid-Induced NeurotoxicityOpioid toleranceMild myoclonus (eg. with sleeping)Severe myoclonusSeizures, DeathDeliriumAgitationMisinterpreted as PainOpioids IncreasedHyperalgesiaMisinterpreted as Disease-Related PainOpioids Increased
38OIN: TreatmentSwitch opioid (rotation) or reduce opioid dose; usually much lower than expected doses of alternate opioid required… often use prn initiallyHydrationBenzodiazepines for neuromuscular excitation
39Adjuvant Analgesics first developed for non-analgesic indications subsequently found to have analgesic activity in specific pain scenariosCommon uses:pain poorly-responsive to opioids (eg. neuropathic pain), orwith intentions of lowering the total opioid dose and thereby mitigate opioid side effects.
40Adjuvants Used In Palliative Care General / Non-specificcorticosteroidscannabinoids (not yet commonly used for pain)Neuropathic PaingabapentinantidepressantsketaminetopiramateclonidineBone Painbisphosphonates(calcitonin)
41} CORTICOSTEROIDS AS ADJUVANTS ¯ inflammation ¯ edema ¯ spontaneous nerve depolarization}¯ tumor mass effects
42CORTICOSTEROIDS: ADVERSE EFFECTS IMMEDIATELONG-TERMPsychiatricHyperglycemia risk of GI bleedgastritisaggravation of existing lesion (ulcer, tumor)ImmunosuppressionProximal myopathy often < 15 daysCushing’s syndromeOsteoporosisAseptic / avascular necrosis of bone
43DEXAMETHASONE minimal mineralcorticoid effects po/iv/sq/?sublingual routesperhaps can be given once/day; often given more frequentlyIf an acute course is discontinued within 2 wks, adrenal suppression not likely
45Gabapentin Common Starting Regimen 300 mg hs Day 1, 300 mg bid Day2, 300 mg tid Day 3, then gradually titrate to effect up to 1200 mg tidFrail patients100 mg hs Day 1, 100 mg bid Day 2, 100 mg tid Day 3, then gradually titrate to effect
46Incident PainPain occurring as a direct and immediate consequence of a movement or activity
47Circumstances In Which Incident Pain Often Occurs Bone metastasesNeuropathic painIntra-abd. disease aggravated by respiration“incident” = breathingruptured viscus, peritonitis, liver hemorrhageSkin ulcer: dressing change, debridementDisimpactionCatheterization
48Having a steady level of enough opioid to treat the peaks of incident pain... ...would result in excessive dosing for the periods between incidentsPainIncidentIncidentIncidentTime
49Fentanyl and Sufentanil synthetic µ agonist opioidshighly lipid solubletransmucosal absorption; effect in approx 10 minrapid redistribution, including in / out of CSF; lasts approx 1 hr.fentanyl » 100x stronger than morphinesufentanil » 1000x stronger than morphine10 mg morphine» 10 µg sufentanil» 100 µg fentanyl
50INCIDENT PAIN PROTOCOL (see alsoStep #Medication (50 mg/ml)# Micrograms Sublingually1Fentanyl502Sufentanil2534100
51INCIDENT PAIN PROTOCOL ctd... fentanyl or sufentanil is administered SL 10 min. prior to anticipated activityrepeat q 10min x 2 additional doses if neededincrease to next step if 3 total doses not effectivephysician order required to increase to next step if within an hour of last dosethe Incident Pain Protocol may be used up to q 1h prn