Nikki Burger GP Registrar November 2005 Palliative Care Nikki Burger GP Registrar November 2005

WHO Definition Palliative Care The active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of best quality of life for patients and their families.

Components of Palliative Care Effective symptom control Effective communication Rehabilitation – maximising independence Continuity of care Coordination of services Terminal care Support in bereavement

Funding Differs from the rest of the health service 20% inpatient units in UK funded entirely by NHS Voluntary sector Goodwill and fundraising initiatives in local communities

Funding National charities Macmillan Cancer Relief Marie Curie Cancer Care Sue Ryder Foundation These are the three major providers nationally.

Concept of Total Pain Physical pain Anger Depression Anxiety All affect patient’s perception of pain. Needs thorough assessment 90% can be controlled with self-administered oral drugs

Depression Loss of social position Loss of job prestige, income Loss of role in family Insomnia and chronic fatigue Helplessness Disfigurement

Anxiety Fear of hospital, nursing home Fear of pain Worry about family and finances Fear of death Spiritual unrest Uncertainty in future

Anger Delays in diagnosis Unavailable physicians Uncommunicative physicians Failure of therapy Friends who don’t visit Bureaucratic bungling

Treatment options Analgesic drugs Adjuvant drugs Surgery Radiotherapy Chemotherapy Spiritual and emotional support (total pain)

Analgesic drugs Mainstay of managing cancer pain Choice based on severity of pain, not stage of disease Standard doses, regular intervals, stepwise fashion Non-opiod…weak opioid…strong opiod…+-adjuvant at any level (WHO analgesic ladder)

Non-opioid drugs Paracetamol 1g 4 hourly NSAIDS Ibuprofen 400mg 4 hourly Aspirin 600mg 4 hourly NB daily maximum doses

Weak opioids Codeine 60mg 4 hourly Dihydrocodeine 30-80mg tds max 240mg daily Dextropropoxyphene 65mg four hourly Tramadol 50-100mg 6 hourly Prescribing more than the maximum daily dose will increase s/e without producing further analgesia

Combinations Convenient Care with dosing Some combinations e.g co-codamol contain subtherapeutic doses of weak opioid Co-proxamol only contains 325mg paracetamol Get dosing right before moving on to strong opioids

Strong Opioids Morphine Hydromorphone Fentanyl Diamorphine Buprenorphine

Morphine Where possible dose by mouth Dose tailored to requirements Regular intervals – prevent pain from returning No arbitrary upper limit (unlike weak opioids) Fears of patients and family Side effects

Morphine Products Oramorph 4 hourly Sevredol 4 hourly Oramorph RS 12 hourly Zomorph 12 hourly MST 12 hourly MXL 24 hourly

Starting Morphine - Dose titration Start with quick-release formulation Prescribe regular four hourly dose, allow same size dose PRN in addition for breakthrough pain, as often as necessary Usual starting dose 5-10mg four hourly After 24-48 hours daily requirements can be calculated

Dose titration Once total dose required in 24 hours known, prescribe it as SR preparation (eg MST) bd Provide additional doses of IR morphine (eg Oramorph) for breakthrough pain at 1/6 of total daily dose If taking regular top-ups recalculate the total daily dose

Dose titration Example – Mrs M 56y breast cancer with bony mets Paracetamol 1g qds Diclofenac SR 75mg bd MST 60mg bd Taking three doses Oramorph a day for breakthrough pain What next?

Calculate total daily dose 60mg bd MST = 120mg (120/6) x3 = 60mg Total 180mg

So, prescribe 180/2 = MST 90mg bd 180/6 = Oramorph 30mg PRN for breakthrough pain.

Parenteral opiates Unable to maintain dosing by mouth Subcutaneous infusion commonest alternative – syringe driver Convert oral dose to equianalgesic sc dose Morphine /2 Diamorphine /3 Fentanyl patch Less constipation, nausea, sedation

Opioid alternatives to morphine Hydromorphone 7 times more potent than morphine, so care in those with no prior exposure

Opioid alternatives to morphine Fentanyl Self-adhesive patches Changed every 72 hours No IR form so for chronic stable pain, need IR morphine for breakthrough 24-48 hours for peak levels to be achieved Useful if side effects with morphine

Oxycodone OxyContin OxyNorm 10mg oral oxycodone = 20mg oral morphine Onset 1 hour, 12 hour modified release OxyNorm Liquid and capsules Immediate release 10mg oral oxycodone = 20mg oral morphine

Hydromorphone Palladone and Palladone SR 1.3mg hydromorphone = 10mg morphine

Writing a prescription for CDs By hand In ink Name and address patient Name of drug Form and strength Total quantity, or number of dose units, in both words and figures

Writing a prescription for opiates Mary Jones 16 High Street, Worcester, WR1 1AA Oramorph liquid 20mg/5ml Supply 200ml (two hundred) Take 20mg every 4 hours Oramorph 10mg/5ml no longer a CD

Side effects of Opiates Common Constipation N+V Sedation Dry mouth Less common Miosis Itching Euphoria Hallucination Myoclonus Tolerance Respiratory depression

Constipation Develops in almost all patients Prescribe PROPHYLACTIC laxatives Start with stimulant AND softener Senna TT nocte PLUS Docusate or lactulose Also common with weak opioids

Nausea and vomiting Initially very common Usually resolve over a few days Easily controlled if forewarned Metoclopramide 10mg 8 hourly Haloperidol 1.5mg bd or nocte

Sedation Also common initially and then resolving Be alert to possibility of recurrence of sedation or confusion after dose alteration

Dry mouth Often most troublesome symptom Simple measures Frequent sips cold drinks Sucking boiled sweets Ice cubes/frozen fruit segments Eg pineapple or melon

Addiction Often feared by inexperienced prescribers and patients and families Escalating requirements are sign of disease progression or possibly tolerance, not addiction

Opioid toxicity Wide variation in toxic doses between individuals and over time Depends on Degree of responsiveness Prior exposure Rate of titration Concomitant medication Renal function

Opioid toxicity Subtle agitation Shadows at periphery of visual field Vivid dreams Visual hallucinations Confusion Myoclonic jerks

Agitated confusion Often misinterpreted as patient being in pain Thus further opioids are prescribed Vicious cycle, leads to dehydration Accumulation of metabolites componds toxicity Management Reduce dose of opioid Haloperidol 1.5-3mg SC/PO hourly as needed for agitation Adequate hydration

Opioid responsiveness Not all pains respond well Bone pain Neuropathic pain Need adjuvants Drugs Radiotherapy Anaesthetic blocks

Common adjuvant analgesics NSAIDS Corticosteroids Antidepressant/-convulsants Bisphosphonates Bone pain Soft tissue inflitration Hepatomegaly Raised ICP Soft tissue infiltration Nerve compression Nerve infiltration Paraneoplastic neuropathy

Bone pain Paracetamol Morphine NSAIDS Radiotherapy Bisphosphonates

Neuropathic pain Features which suggest neuropathic pain Burning Shooting/stabbing Tingling/pins and needles Allodynia Dysaesthesia Dermatomal distribution

Neuropathic pain Antidepressant Anticonvulsant Steroids Amitriptyline 50mg nocte Anticonvulsant Sodium Valproate 200mg bd (or Gabapentin or Carbamazepine) Steroids Dexamethasone 12mg daily Antiarrhythmics Mexiletine 50-300mg tds (or flecainide or lignocaine) Anaesthetics Ketamine Nerve blocks and spinal anaesthesia

Neuropathic pain Complementary therapies TENS Acupuncture Hypnosis Aromatherapy Counselling Social support

Common mistakes in cancer pain management Forgetting there is more than one pain Reluctance to prescribe morphine Failure to use non-drug treatments Failure to educate patient about treatment Reducing interval instead of increasing dose

Any questions?

Reflective Learning Why? Improve your insight into patients illness Improve your relationship with patient or identify stumbling blocks Improve your overall management of the whole patient Identify gaps in knowledge Fulfill the role of holistic practitioner offering care at end of life

Reflective Learning How has the diagnosis affected your relationship with the patient? Do you feel uncomfortable in your attempts to communicate with the patient or family? Have you explored the patients worries about their illness? Have you explored their views on their treatment so far? Do you feel that you have been of help? Can you identify stages of “anticipatory grief”?

Other areas for future learning Breathlessness and cough Mouth care/skin care/lymphoedema N+V and intestinal obstruction Anorexia, cachexia and nutrition Constipation and diarrhoea Non-cancer palliative care Emergencies Children Caring for carers Bereavement