Pain and Symptom Management Fran MacIvor Locum Consultant, Palliative Medicine

Pain basics, and a little bit about nausea and constipation

Important things from today…. Pain – its not all the same Importance of details How to prescribe strong analgesia

Types of pain Visceral pain Nerve TOTAL PAIN Musculo-skeletal (somatic) Bone pain

Assessment Nature Pattern (Breakthrough? End of dose? Incident?) Severity / intensity (see scales*) Effect of current analgesia What do they think is the cause?

Visual pain scales

Analgesia – the basics The WHO ladder Sorts out 80 – 90% of pain if used properly

Case Mr. B, 60 y.o. man Lung cancer Invasion of ribs on right Tramadol 100mg QDS, paracetamol 1g QDS Still in pain….

Initiating Step 3 - Opiates Initiating Opiates

Introducing opiates – a safe start… Start with simple morphine unless there is a reason not to Use prn doses of short acting morphine (oramorph) initially to assess a) effectiveness b) side effects? Calculate total dose of oramorph used over previous 24 hours Divide total in two and give as long acting MST BD

Give 1/6th of total 24 hour dose, as required for breakthrough, up to once every hour if needed Next day, look again at total breakthrough used and titrate up long-acting MST appropriately Remember the breakthrough dose may need to be increased too REMEMBER S/C MORPHINE IS 2X AS STRONG AS ORAL ie. HALVE THE ORAL DOSE

Reasons for caution…… Signs of opiate toxicity Drowsy Confused Myoclonic jerks Hallucinations (visual peripheral especially) Nausea Pupils Respiratory depression

Case Mrs G. 90 year old Pathological fracture of hip Dementia, NH resident Communication difficult What issues might there be in providing adequate pain relief?

Examples of adjuvants Anticonvulsants Antidepressants Steroids Muscle relaxants Bisphosphonates Chemo / radiotherapy Surgery

Opiate switching Alternatives to morphine; Oxycodone Hydromorphone Fentanyl / Alfentanil Diamorphine Methadone

Nausea and Vomiting Common causes are common! Drugs Treatments Tumour type and position

Constipation Poor oral intake does not mean no poo Immobility Drugs Disruption of habit Altered gut function Always prescribe a laxative with opiates

Factors associated with worse experience of nausea/vomiting Tumour type Female Younger than 50 History of travel sickness Anxious personality

Causes of nausea and vomiting

Put right what you can… Rehydrate Treat blood abnormalities (Ca, Urea etc.) Stop offending drugs GET BOWELS MOVING

Anticipatory/anxiety Drugs (v. simplified) Main cause First choice Bowel problem Metoclopramide/Domp. (ondansetron) Swelling Steroid Abnormal blood/ Drugs Haloperidol Chemo/radiotherapy Ondansetron/Aprep. Anticipatory/anxiety Lorazepam All above/ Don’t know Levomepromazine

Help with symptoms HPCT (Tay-UHB.palliative@nhs.net) www.palliativecareguidelines.scot.nhs.uk Palliativedrugs.com