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Pain Management In Palliative Care

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Palliative Care – An Overview

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1 Pain Management In Palliative Care
Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, WRHA Palliative Care Medical Director, Pediatric Symptom Management Service

2 Pain An 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

3 Clinical 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 skin Hyperalgesia – An increased response to a stimulus which is normally painful Hyperesthesia - 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.

4 Approach To Pain Control in Palliative Care
Thorough assessment by skilled and knowledgeable clinician History Physical Examination Pause here - discuss with patient/family the goals of care, hopes, expectations, anticipated course of illness. This will influence consideration of investigations and interventions Investigations – X-Ray, CT, MRI, etc - if they will affect approach to care Treatments – pharmacological and non-pharmacological; interventional analgesia (e.g.. Spinal) Ongoing reassessment and review of options, goals, expectations, etc.

5 Sympathetic Maintained
TYPES OF PAIN NOCICEPTIVE NEUROPATHIC Somatic bones, joints connective tissues muscles Deafferentation Sympathetic Maintained Peripheral Visceral Organs – heart, liver, pancreas, gut, etc.

6 Somatic Pain Aching, often constant May be dull or sharp
Often worse with movement Well localized Eg/ Bone & soft tissue chest wall

7 Special Considerations in Bone Pain
Spinal cord compression in vertebral mets: Pain = earliest feature Risk of pathological fracture Indications for prophylactic surgery in large, weight-bearing bones Cortical Lesions Destruction of > 50% of the cortical width Axial length of lesion > diameter of the bone > 2 – 3 cm lesion Medullary lesions Lesion > 50% of the medulla Pain unrelieved by radiotherapy

8 Visceral Pain Constant or crampy Aching Poorly localized Referred Eg/
CA pancreas Liver capsule distension Bowel obstruction

COMPONENT DESCRIPTORS EXAMPLES Steady, Dysesthetic Burning, Tingling Constant, Aching Squeezing, Itching Allodynia Hypersthesia Diabetic neuropathy Post-herpetic neuropathy Paroxysmal, Neuralgic Stabbing Shock-like, electric Shooting Lancinating trigeminal neuralgia may be a component of any neuropathic pain

10 Pain Assessment

11 “Describing pain only in terms of its intensity is like describing music only in terms of its loudness” von Baeyer CL; Pain Research and Management 11(3) 2006; p

12 PAIN HISTORY Description: severity, quality, location, temporal features, frequency, aggravating & alleviating factors Previous history Context: social, cultural, emotional, spiritual factors Meaning Interventions: what has been tried?

13 Example Of A Numbered Scale

14 Medication(s) Taken Dose Route Frequency Duration Efficacy
Adverse effects

15 Physical Exam In Pain Assessment Inspection / Observation
“You can observe a lot just by watching” Yogi Berra Overall impression… the “gestalt”? Facial expression: Grimacing; furrowed brow; appears anxious; flat affect Body position and spontaneous movement: there may be positioning to protect painful areas, limited movement due to pain Diaphoresis – can be caused by pain Areas of redness, swelling Atrophied muscles Gait Myoclonus – possibly indicating opioid-induced neurotoxicity

16 Physical Exam In Pain Assessment Palpation
Localized tenderness to pressure or percussion Fullness / mass Induration / warmth

17 Physical Exam In Pain Assessment Neurological Examination
Important in evaluating pain, due to the possibility of spinal cord compression, and nerve root or peripheral nerve lesions Sensory examination Areas of numbness / decreased sensation Areas of increased sensitivity, such as allodynia or hyperalgesia Motor (strength) exam - caution if bony metastases (may fracture) Deep tendon reflexes – intensity, symmetry Hyperreflexia 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

18 Physical 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.

19 Pain Treatment

20 Non-Pharmacological Pain Management
Acupuncture Cognitive/behavioral therapy Meditation/relaxation Guided imagery TENS Therapeutic massage Others…

21 W.H.O. ANALGESIC LADDER 3 2 1 Strong opioid +/- adjuvant Weak opioid
By the Clock Strong opioid +/- adjuvant 2 Weak opioid +/- adjuvant Pain persists or increases 1 Non-opioid +/- adjuvant

22 STRONG OPIOIDS most commonly use: morphine Hydromorphone (Dilaudid ®)
transdermal fentanyl (Duragesic®) oxycodone Methadone DO NOT use meperidine (Demerolâ) long-term active metabolite normeperidine ® seizures

OPIOIDS and INCOMPLETE CROSS-TOLERANCE conversion tables assume that tolerance to a specific opioid is fully “crossed over” to other opioids. cross-tolerance unpredictable, especially in: high doses long-term use divide calculated dose in ½ and titrate

24 Approximate Equipotency with Morphine (Morphine:Drug)
Hydromorphone 5:1 Oxycodone 1.5:1 to 2:1 Codeine 1:12 Methadone Daily Morphine Dose 30 – 90 mg 3.7:1 90 – 300 mg 7.75:1 > 300 mg 12.75:1 Fentanyl 80:1 to 100:1 (for subcutaneous dosing of each) NB: Does not consider incomplete cross-tolerance

25 TITRATING OPIOIDS dose increase depends on the situation
dose ­ by % EXAMPLE: (doses in mg q4h)





30 TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the same effect Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

31 PHYSICAL DEPENDENCE A normal physiological phenomenon in which a withdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

and ADDICTION A 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 drug Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

33 po / sublingual / rectal routes SQ / IV / IM routes
Changing Route Of Administration In Chronic Opioid Dosing po / sublingual / rectal routes SQ / IV / IM routes reduce by ½

34 Using Opioids for Breakthrough Pain
Patient must feel in control, empowered Use aggressive dose and interval Patient Taking Short-Acting Opioids: % of the q4h dose, given q1h prn Patient Taking Long-Acting Opioids: % of total daily dose given, q1h prn with short-acting opioid preparation

35 Opioid Side Effects Constipation – need proactive laxative use
Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol) Urinary retention Itch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great success Dry mouth Respiratory depression – uncommon when titrated in response to symptom Drug interactions Neurotoxicity (OIN): delirium, myoclonus ® seizures


37 Misinterpreted as Pain Misinterpreted as Disease-Related Pain
Spectrum of Opioid-Induced Neurotoxicity Opioid tolerance Mild myoclonus (eg. with sleeping) Severe myoclonus Seizures, Death Delirium Agitation Misinterpreted as Pain Opioids Increased Hyperalgesia Misinterpreted as Disease-Related Pain Opioids Increased

38 OIN: Treatment Switch opioid (rotation) or reduce opioid dose; usually much lower than expected doses of alternate opioid required… often use prn initially Hydration Benzodiazepines for neuromuscular excitation

39 Adjuvant Analgesics first developed for non-analgesic indications
subsequently found to have analgesic activity in specific pain scenarios Common uses: pain poorly-responsive to opioids (eg. neuropathic pain), or with intentions of lowering the total opioid dose and thereby mitigate opioid side effects.

40 Adjuvants Used In Palliative Care
General / Non-specific corticosteroids cannabinoids (not yet commonly used for pain) Neuropathic Pain gabapentin antidepressants ketamine topiramate clonidine Bone Pain bisphosphonates (calcitonin)

41 } CORTICOSTEROIDS AS ADJUVANTS ¯ inflammation ¯ edema
¯ spontaneous nerve depolarization } ¯ tumor mass effects

IMMEDIATE LONG-TERM Psychiatric Hyperglycemia ­ risk of GI bleed gastritis aggravation of existing lesion (ulcer, tumor) Immunosuppression Proximal myopathy often < 15 days Cushing’s syndrome Osteoporosis Aseptic / avascular necrosis of bone

43 DEXAMETHASONE minimal mineralcorticoid effects
po/iv/sq/?sublingual routes perhaps can be given once/day; often given more frequently If an acute course is discontinued within 2 wks, adrenal suppression not likely

44 Treatment of Neuropathic Pain
Pharmacologic treatment Opioids Steroids Anticonvulsants – gabapentin, topiramate TCAs (for dysesthetic pain, esp. if depression) NMDA receptor antagonists: ketamine, methadone Anesthetics Radiation therapy Interventional treatment Spinal analgesia Nerve blocks

45 Gabapentin 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 tid Frail patients 100 mg hs Day 1, 100 mg bid Day 2, 100 mg tid Day 3, then gradually titrate to effect

46 Incident Pain Pain occurring as a direct and immediate consequence of a movement or activity

47 Circumstances In Which Incident Pain Often Occurs
Bone metastases Neuropathic pain Intra-abd. disease aggravated by respiration “incident” = breathing ruptured viscus, peritonitis, liver hemorrhage Skin ulcer: dressing change, debridement Disimpaction Catheterization

48 Having a steady level of enough opioid to treat the peaks of incident pain...
...would result in excessive dosing for the periods between incidents Pain Incident Incident Incident Time

49 Fentanyl and Sufentanil
synthetic µ agonist opioids highly lipid soluble transmucosal absorption; effect in approx 10 min rapid redistribution, including in / out of CSF; lasts approx 1 hr. fentanyl » 100x stronger than morphine sufentanil » 1000x stronger than morphine 10 mg morphine » 10 µg sufentanil » 100 µg fentanyl

(see also Step # Medication (50 mg/ml) # Micrograms Sublingually 1 Fentanyl 50 2 Sufentanil 25 3 4 100

fentanyl or sufentanil is administered SL 10 min. prior to anticipated activity repeat q 10min x 2 additional doses if needed increase to next step if 3 total doses not effective physician order required to increase to next step if within an hour of last dose the Incident Pain Protocol may be used up to q 1h prn

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