The Mary Stevens Hospice Stourbridge Lucy Martin - Medical Director (BCVTS 1997 – 2000!)

VTS March 4th 2010 1.30 Session on Palliative Care and Basics of Pain Control, plus discussion and questions 2.45 Coffee / Tea 3.00 Case discussion 1 & feedback 3.45 Case discussion 2 & feedback 4.30 Plenary and close

What is Palliative Care?

WHO Definition Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

provides relief from pain and other distressing symptoms affirms life and regards dying as a normal process intends neither to hasten or postpone death integrates the psychological and spiritual aspects of patient care offers a support system to help patients live as actively as possible until death offers a support system to help the family cope during the patient's illness and in their own bereavement

uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated will enhance quality of life, and may also positively influence the course of an illness is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

Who provides Palliative Care?

Generalist Specialist GPs, District Nurses, Hospitals Providing day-to-day care in hospital or patients home Specialist Palliative Care Teams based in hospices, hospitals, community Multidisciplinary – Core members are doctors & nurses, AHPs In-patient and Day care facilities, hospice at home Ongoing advice and support in any setting Bereavement support Education and training for specialists and generalists

Day Unit 1993, Residential Unit 1999 Day care since 1993, and residential since 1999 Referral form @ www.marystevenshospice.co.uk

Specialist Palliative Care in Dudley Hospice in-patient care / day care Mary Stevens covers the whole Dudley borough Hospital in-patient care no dedicated hospital beds 0.4 WTE consultant – out pt and consultation hospital palliative care team & MDT meeting Community Service Macmillan CNS and OT / Physio team Palliative Care end of life team

What you know about pain management? What do you feel confident about? What makes you nervous?

WHO ladder / lift Cancer and non-cancer chronic pain Dudley Pain Management Guidelines

Principles of analgesic use By the mouth By the clock By the ladder Refers to WHO analgesic ladder Treatment should be individualised Use adjuvants Drugs for specific situations e.g. Neuropathy Drugs to control side effects Psychotropics Twycross, R ‘Introducing Palliative Care’, ‘Symptom management of advanced cancer’

Titration and choice of opioid Titration and choice of opioid. Rationale for not choosing several opioids at the same time. Compare and contrast the different strong opioids. The rise and rise of the transdermal route.

Strong opioids Should be given according to need and response Should not be given according to prognosis Administration still surrounded by concern

Little clinically significant respiratory depression, tolerance not a problem, dependence does not occur Naloxone – very rare Patients generally have been receiving weak opiates first Dose gets titrated – ‘start low, go slow’ Pain is an antagonist to central depressant effects of strong opiates Therapeutic dose vs. toxic / lethal dose

Opioids in the well person (or How I did it by H. Shipman)

Opioids in Cancer Pain (and probably non-cancer pain too)

Morphine Pros Cons 200+ years of experience Cheap 4 formulations – IR elixir and tablet, SR liquid and tablet / capsule Flexibility in dosing, multiple strengths available, flexible routes Predictable titration schedule Metabolites accumulate in brain and CSF if renal dysfunction 20 – 30 % population do not tolerate

Equivalent Doses Comfortable Dose for Rx Equivalent 24hr Morphine Dose Codeine 60mg qds p.o. Dihydrocodeine 60mg qds p.o. Pethidine 50mg qds p.o. Tramadol 100mg qds p.o. Fentanyl 25mcg t.d. Diamorphine 2.5mg s.c. every 30 mins Morphine 25mg Morphine 40 - 80mg Morphine 60mg Morphine 7.5mg p.o. every 30 mins

Titrating in the community Easiest method is the 4-hourly plus rescue Calculate current morphine equivalent / 24hr +/- make allowance for uncontrolled pain Divide by 6 4 hourly dose / rescue dose 2 – 3 days record Review, then divide and convert to sustained release prep, plus rescue (1/6th of total daily dose)

Increasing doses of opioid Gradual escalation of doses if pain control inadequate Dose escalations of less than 30 – 50% are unlikely to have much effect Experience shows 30 – 50% dose increases are safe Absolute dose is immaterial as long as balance between analgesia / side effects Less is known about titration for dyspnea

Why / when to switch opioid Intolerable side effects Itching, neurotoxicity, that persist despite appropriate intervention Lack of desired analgesic effect Even with rapidly escalating doses Moderate or severe renal disease Egfr <60 ?? Alternative route is required Unstable pain on a patch Patient’s personal choice / opiophobia

Diamorphine Pros Cons Cheap May work via receptors other than µ - explaining the apparent differences with morphine More soluble / lipophilic than morphine – parenteral use /small volumes Quicker action, less vomiting Not useful orally More sedating than morphine Fear / preconceptions of patients and HCPs

Oxycodone Pros Cons Potent drug orally Flexibility in SR dose formulations Effective levels within 1 hour – good for titration Rectal formulation Metabolites not part of the analgesic picture Possibility of neuropathic effect Differing views in different countries – USA see it as a step 2 drug Common drug of abuse in USA

Hydromorphone (palladone) Pros Cons Multiple routes of admin – oral, parenteral, rectal and intraspinal Very soluble – good for subcut use Oral dosing complicated and oral breakthrough dose multiple capsules Difficulty predicting dose equivalency with morphine

Fentanyl & alfentanil Pros Cons Transdermal delivery due to lipophilic nature Intravenous – rapid onset of action Buccal / sublingual / intranasal immediate release formulation Convenience / compliance Possibly less constipation Delay of effective analgesia 8 -12 hrs initially Poor dosing flexibility Uncertainty with BMI Cost Contraindication in uncontrolled pain due to titration period Patch adhesion problems

Methadone Pros Cons Potent orally Useful in pain with neurological components Unpredictable accumulation / plasma concentration rises over long periods – unpredictable side effects Steady state ~ 1 week Not really practical in community setting

Please don’t forget Constipation Nausea senna/ lactulose movicol co-danthrusate / co-danthramer Nausea metoclopramide / domperidone haloperidol

Where to look for information? Twycross books are the ‘bibles’ Palliative Care Formulary – 3rd Edition Symptom management of advanced cancer - 4th Edition Introducing Palliative Care Palliativedrugs.com – online version of PCF More detail Oxford Textbook of Palliative Medicine West Midlands pain handbook