Dr Amanda Landers Community Palliative Medicine Specialist
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
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
Psychological Anxiety Depression Insomnia Existential suffering which may lead to thoughts of euthanasia
Immunological Decreased natural killer cell counts ? Other effects on the immune system
Impending death Decreased enjoyment and quality of life Disability Suffering long-term Challenges to dignity Burden to others
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
paracetamol licensed by FDA 1950s dose 500mg – 1g 4 to 6 hourly for all maximum 4g in 24 hours for all
60kg, frail 84 year old woman1g QDS 106kg, 30 year old 1g QDS 70kg, 65 year old man1g QDS
maximum 4g in 24 hours
fit young 18 years to 30 years fit elderly > 65 years frail elderly> 65 years (+CVA or hospitalised)
fit young 18 years to 30 years CL100% fit elderly > 65 years CL70-80% frail elderly> 65 years CL50-55% (+CVA or hospitalised)
Maybe non frail elderly 1g TDS frail elderly 1g BD What about the 30 to 65 year olds?
Man admitted to hospital with worsening chest wall pain Oncology ward full so placed on an ‘outlying’ ward
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.
Results: non-opioids more frequently in non- oncology units (19.6% versus 7.0%; P < ) strong opioids are more frequently used in the oncology units (69.5% versus 51.9%; P < ). 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.
Man started on morphine regularly Switched to long-acting formulation GP mentions fentanyl patches to him in the community
Fentanyl Oxycodone Methadone (Hydromorphone) (Sufentanil) (Combination drugs)
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
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 hours May need to be changed every 2 days in minority of patients
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
Synthetic opioid; NMDA activity Oral to parenteral conversion usually 1:1 Still much confusion and controversy about pharmacokinetics; t1/2 varies from hrs! very potent and small doses should be prescribed “ Start low, go slow”. ?initiate in hospital setting
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?
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
Man rotated onto methadone in the hospice Neuropathic element to pain Co-analgesics also started
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.
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
Non-opioids Limited usefulness but may be worth a trial Opioids Co-analgesics Steroids Anti-convulsants Tricyclic antidepressants Systemic local anaesthetics Benzodiazepines
Used for nerve pain and depression Common side effects Dry mouth Blurred vision Urinary retention Drowsiness Lowers seizure threshold
Used for nerve pain Common side effects Easy bruising dizziness ataxia headache twitching peripheral oedema
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
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
SC lignocaine Affects sodium channels Contraindicated in hepatic dysfunction and severe cardiac rhythm disturbances
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