Dr Barbara Downes June 2013

Introduction Patient group An over view of managing pain Revision of the basics Case examples Drugs and conversions in the next session

Pain Management in Palliative Care Pain caused by cancer Pain in the last months of life Distinct from but overlaps with Acute and Chronic Pain Management Far more than the prescription of analgesia

First Things First Pain is frightening A calm reassuring approach can be as effective as analgesia Get the relatives ‘onboard’ Leave them all with a plan of action Be familiar with analgesia and its use

1. Know what you are dealing with

A 5 minute pain assessment Is this an exacerbation or a new pain? What is known of the past history? What is the nature of the pain-?neuropathic features Any significant findings on examination? What is the likely cause(s) of pain? Are any causes reversible?

Assessment continued What drugs have been prescribed? Are they taken and with what effect? If not taken, why not? What does the patient understand ? Are there any influencing psychosocial factors?

Patient Age, Ca pancreas, wife, 2 children Abdo pain since diagnosis 2 years ago Pain unchanged despite surgery, XRT, chemo, nerve block and large doses of analgesia Frequent pain crises/calls for help

Exacerbating factors Hospital appointments Scan results School holidays Noisy neighbours Boredom Family distress Thoughts

2. Understand the basics of analgesia

Practical Pain Relief Remember the analgesic ladder-go up not sideways Use the oral route unless unable Use morphine first line Titrate Use correct PRN dose of immediate release preparation Deal with any anxieties about analgesia Anticipate side effects

Patient Frequent call outs for pain Injectables prescribed Would wait a few hours for the DN to arrive Confidence in oral analgesia undermined Very short term solution, crises continued

Titration of Analgesia Start small, build up doses until pain is controlled Use modified release and immediate release preparations Prescribe adjuvent drugs Review frequently If making no progress, re-think pain and management strategy

3.Understand break through pain and use of PRNs

Break through pain May indicate a need to increase regular analgesia May be ‘incident’ pain Some patients need ‘regular’ PRNs The dose of PRN medication should be 1/6 th of regular oral analgesia Fentanyl patches IR fentanyl preparations

Patient Mesothelioma Concerned wife Pain well controlled Given PRN morphine regularly no matter what the dose of MST Potential to ‘over do’ opiates Patient and wife happier with frequent PRNs

Remember adjuvent analgesia Paracetamol NSAID Steroids-enlarged liver, pressure pain Hyoscine butylbromide- colic Amitriptyline, gabapentin or pregabalin – neuropathic pain

Fentanyl Patches Strong analgesia Unable to swallow, vomiting, tablet burden, poor tablet compliance Titrate slowly, each 25mcg patch = 80mg morphine Dose of PRN morphine /oxycodone in proportion to the patch strength (100mcg patch = 60mg morphine solution prn)

Remember non-drug measures Understanding Relaxation Physio/OT Psychology TENS Heat pads

4. Should analgesia be decreased?

Too much analgesia? After pain modifying treatment eg XRT, nerve block Complaints of pain are cries for help/reassurance No response to escalating doses of analgesia

Patient Poor pain control despite: Fentanyl 150mcg, IR morphine 100mg multiple times, diazepam 5mg x4 Frequent cries for help Each time drug changed/increased but only short term gain Spaced out Disease stable Agreed to admission for review

Progress Back to basics Fentanyl discontinued 4hrly oxycodone liquid Discharged on oxycodone MR 40 mg BD More alert, functioning better Coping strategies, psychology,

5. Anticipate difficulties with the oral route at the end of life

At the End of Life Analgesia must be continued but often becomes simpler Replace morphine/oxycodone with sc infusion Continue fentanyl patch if used Prescribe prn sc analgesia for all Use conversion tables for doses or seek advice

6. Think about continuity of management

Too Many Cooks? Multiple GPs, OOH GPs, DNs, Specialist nurses, oncology, palliative care, family etc All have a differing opinion Each encounter has potential to change/increase analgesia not always appropriately Patients become confused and confidence undermined. Communication; ? lead doctors?

Finally Know what you are dealing with—assess Titrate opioids and adjuvant drugs Review Understand influencing factors Have a plan of management Communicate the plan to the patient and family Help them adapt/adjust to pain and the limitations of analgesia. Refer