1. Treatment in Palliative Care

2. Symptom management evaluation individualized treatment explanation
supervision
attention to detail

3. ACUTE PAIN
Rapid pulse
Raised blood pressure
Dilated pupils
Quiet, rubbing part, guarding painful area
Reports pain
CHRONIC PAIN
Normal blood pressure
Normal pupil size
Normal activity, perhaps limited in nature
May not even mention pain unless questioned

4. Main problems Pain Constipation Lack of appetite Loss of weight
Sleepnessness
Anxiety
Nausea and vomiting
Powerlessness
Dyspnoe

5. Main problems Symptom Bedard 1991 N=952 (%) Coyle 1990 N=90 (%) Pain
12-30 34
Dyspnoea 9 28
Nausea 16 13
Vomites -
Sleepnessness 5 57
Orientation disorders 4
Fatique 52
Anorexy 14 6
Incontinency of urine

6. Pain is what the patient says hurts

7. Total pain
Physical pain basal disease, coexisting illnesses, results of treatment
Psychological suffering anxiety, depression
Spiritual suffering existential and religious problems,
DAME CECILY SAUNDERS
Czynniki obniżające próg bólu: zmęczenie, bezsenność, lęk, złość, depresja, izolacja

8. PAIN

9. PHYSICAL
PSYCHOLOGICAL
SOCIAL
TOTAL PAIN
SPIRITUAL
Saunders 1967

10. Skale bólu Skala wzrokowo- analogowa Skala oceny liczbowej NRS
Brak bólu ból nie do zniesienia
Brak ulgi w dolegliwościach całkowita ulga

11. Pain ACUTE - CHRONIC NOCICEPTIVE NEUROPATHIC PSYCHOLOGICAL
Neuropat – obwodowy = de -aferentacyjny : może być somatyczny (ból fantomowy, neuropatia obwodowa, neuralgia popółpaśćcowa) i trzewny ( np.naciekanie nerwów trzewnych ok.. Paraaortalnej).

12. Nociceptive pain STIMULATION OF NERVE ENDINGS
visceral ( colic, migraine, cancer)
somatic ( cancer, infection, tension headache, cramp, bone)
muscles tension
Neuropat – obwodowy = de -aferentacyjny : może być somatyczny (ból fantomowy, neuropatia obwodowa, neuralgia popółpaśćcowa) i trzewny ( np.naciekanie nerwów trzewnych ok.. Paraaortalnej).

13. Neuropathic pain nerve compression nerve injury
* peripheral (de-afferentation)
- Somatic (peripheral neuropathy, phantom) - Visceral ( infiltration of para-aortic visceral nerves)
* central ( poststroke, spinal cord compression) *sympathetically maintained ( causalgia)

14. Analgetic Ladder WHO 1986
I0 non-opioids + adjuvants
II0 weak opioids + non-opioids adjuvants
III0 strong opioids + non-opioids adjuvants

15. Principles of analgesic use
By the mouth
By the clock
By the ladder
Individual treatment
Supervision
Adjuvant drugs

16. But...
Chronic pain needs to be treated by slow acting medicine PERSISTANTLY...
Breakthrough pain ( predictable , non-predictable, pain of the end dose) needs using occasionally short acting medicine.

17. Non opioids Paracetamol Non- steroid Antiinflamatory Drugs (COX–1)
Ibuprofen
Diclofenac
Ketoprofen
Piroxicam etc
Non- steroid Antiinflamatory Drugs (COX–2)
Acetylsalicylic acid

18. Weak opiois ( II0 WHO) Tramadol 1/5 Codein 1/10 Dihydrocodein 1/10
Oxycodon 1,5 / 1
Dextropropoxyphen
Pentazocin – DO NOT USE !!!
Tramadol – działanie presynaptycznego blokera wychwytu zwrotnego monoamin ( jak trójcykl. ) . Uwaga – obniża próg drgawkowy ! U osób z wywiadem drgawk – nie

19. Tramadol caps 50mg, tabl. forte 100mg,
SR-tabl. –retard- 150, 200mg guttae 1g/10ml (1ml=40gtt.)
agonist of μ -,δ-, κ- receptor
presynaptic bloker of rec. MAO
convulsions threshold is lowered

20. Pentazocin ( Fortral) Partial agonist μ receptor Agonist κ receptor
Pure antagonist δ receptor
Short acting 2-3 h
Psychotomimetic effects
DO NOT USE IN CHRONIC PAIN
dysphoria, depersonalisation, frightening dreams, hallucinations
silny agonista kappa ,
na rec. kappa rdzenia kręg. działa silniej od MF
agonista sigma
byc moze działa na rec. delta
metabolity nieaktywne jako glukuroniany

21. Strong opioids III0 WHO
Morphine hydrochloride ( substance, Sevredol, Vendal,)
Morphine sulphate (Doltard, MST-Continuous, M-Eslon, Vendal, ) /1
Fentanyl ( Durogesic TTS) /1
Buprenorphine (Bunondol, Transtec TTS) 60/1
Methadone /1
Diamorfina ( heroin) /1
Dextromoramid (Palfium) /1
Pethidine (Dolargan) 1/8 – DO NOT USE!!!
Approximate oral analgisic equivalence to Morphine
Buprenorphine ( poch Tebain) small intrinsic activity, partial agonist ( agonist – antagonist) to ,  ? , non-  effect. Sl,

22. Morphine Pure agonist of  receptor Without ceiling-effect
M6G is 10-20x  , M3G (toxic),
First dose 30 mg/24h ( 15mg/24h )
Dose is arised 50% if ineffective
10% of Codein is metabolised to M6G

23. Morphine Morphine hydrochloride Substance
Sevredol tabl mg – short acting
Vendal
Morphinum sulphate 10,30,60,100mg
M-Eslon
MST-Continuous
Doltard
Kapanol

24. Rp.
Morphini hydrochlorici ,0 Aquae destillatae ad ,0 ml M.f. Solutio D.s. ½ ml q4h
600, 1000, 1400, 1800, 2200, ( 200 )

25. Fentanyl Pure agonist  Fentanyl is 150 x  than MF
Lipophilic ( peripheral side effects are not so strong as MF)

26. Pethidine Agonist  Action time – 2-3 h Ceiling effect 600mg/24h
Toxic methabolite– norpethidine
Siede effects: myoclonus, dysphoria,
Indications: acute pain, not use longer than 48 h,
Contraidications: renal failure

27. Sensitization PERIPHERAL
activation of „sleeping receptors”
„inflammatory soup”
CENTRAL – activation of the NMDA receptor-channel complex

28. Wind-up
Chronic irritation of C-fibers , which are proliferated in posterior horns of medullae spinalis and are responsible for potencialization of the impulses ( allodynia)

29. Methadone Agonist -receptor and -receptor Racemic forms: L- i D
NMDA – receptor antagonist
The plasma halflife ranges 8-80 h
Bioavailibility 80% (parenteral)
Lipophilic
Eliminated by alimentary tract in 80% (in renal failure may be used)
5-10 x  than MF, 3-5mg start dose
Metabolites are inactive, 2-3 days patients are advised to take dose q3h as needed , later bd or tds regimen
Ketamine – blockade of NMDA receptor-channel complex . Methadone lipophilic like Fentanyl
Metadone useful, when renal failure ( because M6G is collected and causes drowsiness and delirium )

30. Receptor NMDA Rec NMDA Aminokwasy pobudzające CUN :
Kw` glutaminowy gł przekaźnik pobudzający w mózgu. Oraz endogenny ligand rec. NMDA
Kw. asparaginowy
nawet drgawki
Rec NMDA złożony o wielu miejscach wiązanialigandów endog które biorą udział w otwarciu kanału wapniowego.
Miejsca dla: - kw. glutamin
Kw.N-metylo-D-asparaginowego
Miejsce poliamin
Miejsce glicynowe
Miejsce wiązania jonów Mg i Zn. –zlokalizowane w obrębie kana`łu wapniowego i hamujące funkccję receptora.
Przy potencjale spoczynk. Większo``sc rec NMDA jest zablokowana przez MG ,który blokuje wejście.

31. Opioid Rotation Non effective, toxic
Because- of different types of opioid receptors
Differences in pharmacocinetics and methabolizm of opioids
Be careful in equivalent dose
supports of tolerance – metadon ma większą wewnętrzną aktywność niż MF

32. Muscle spasm Miorelaxants
Baclofen (GABA- agonist) tabl. 10 i 25mg x 5-10 mg
Tyzanidine
Benzodiazepins Midazolam 7,5 – 15 mg p.o. Clonazepam 0,5 mg /nocte Diazepam 5-20 mg p.o.
Baclofen – hamuje przewodzenie odruchów mono -i polisynaptycznych na poziomie rdzenia, prawd. Przez stymulację rec. GABA

33. Adverse effects of opioids
Constipation 100%
Nausea and vomiting – 50%
Drowsiness – 100%
unsteadiness, confusion – initial
Stop urination – be careful !!
Central depressant effects
Psychological dependence
Physical dependence
Occasional – dry mouth, inflammation of mouth, candidiasis, sweating, myoclonus

34. I have tried everything... There is nothing more I can do ...
Never say
I have tried everything...
There is nothing more I can do ...