1. PAIN MANAGEMENT & PALLIATIVE CARE DR TONIA C. ONYEKA CONSULTANT ANAESTHETIST, HEAD, PAIN & PALLIATIVE CARE UNIT, UNTH, ENUGU

2. Objectives Define pain, palliative care Recognize importance of pain assessment in pts with advanced disease Be able to assess pain effectively Discuss an approach to the treatment of pain in the terminally ill

3. PALLIATIVE CARE: World Health Organization 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 prevention & relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

4. 4 Cure/Life-prolongingIntent Palliative/ Comfort Intent Bereavement DEATHDEATH “Active Treatment” PalliativeCare DEATHDEATH EVOLVING MODEL OF PALLIATIVE CARE

6. SUFFERING EMOTIONAL PSYCHOSOCIAL PHYSICAL SPIRITUAL

7. Potential Palliative Conditions A. “The Usual Suspects” – progressive life-limiting illness –Incurable cancer –Progressive, advanced organ failure (heart, lung, kidney, liver) –Advanced neurodegenerative illness (ALS, Alzheimer’s Disease)

8. B. Sudden fatal medical condition –Acute stroke –Withholding or withdrawing life- sustaining interventions (ventilation, dialysis, pressors, food/fluids…) –Trauma – eg. head injury –Ischemic limbs, gut –Post-cardiac arrest ischemic encephalopathy –etc…

9. Potential Palliative Care Interventions Control of Pain Dyspnea Nausea Vomiting Support Emotional Spiritual Psychosocial CPR Ventilation Highly burdensome Interventions Infections Transfusions Hypercalcemia Dialysis Tube Feeding Palliative Generally Not Palliative Variable

10. One most common reasons people seek healthcare One most widely under-treated health problems An unpleasant sensory or emotional experience associated with actual or potential tissue damage or is described in terms of such damage- (IASP)

11. Clinical Terms Associated With Pain Dysesthesia – An unpleasant abnormal sensation, whether spontaneous or evoked. Allodynia – Pain due to a stimulus which does not normally provoke pain, such as pain caused by light touch to the skin Hyperalgesia – An increased response to a stimulus which is normally painful Hyperesthesia - Increased sensitivity to stimulation, excluding the special senses. Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms should be used wherever they are applicable.

12. 60 – 70% of Nigerian cancer patients suffer pain Pain is under-reported and hence grossly under-treated No national studies on the prevalence of pain in hospital patients Few pain specialties exist Problems of opioid availability Current status of Pain

13. Presently part of the Pain & Palliative Care Unit, within the Multidisciplinary Oncology Center, UNTH. Receives cancer and non-cancer pain referrals from all parts of the hospital. Responds to out-patient and peripheral hospital pain management needs. Responsible for the dispensing of oral morphine via its oncology pharmacy unit following production. Role of Pain Team in UNTH

14. Children do not feel pain to the same degree as adults. It is not possible to adequately measure pain in cognitively impaired patients. Physical manifestations of pain are more important than self-report measurements. Pain does not exist in the absence of detectable tissue damage. Common Myths about Pain

15. Symptom Prevalence Pain Fatigue/Asthenia Constipation Dyspnea Nausea Vomiting Delirium Depression

17. Barriers to Pain Control Assume symptom part of disease experience and/or that nothing can be done Fear doctor will stop treatment Fear of addiction and dependence with opioids Being a bother; “Good patients don’t complain” Will distract the doctor care, time trade off Fear pain means disease progression

18. Patient doesn’t report pain: “expected”with disease, testing may hurt or worsen condition Patient/family doesn’t want opioids: addiction, loss of action, dependence Physician doesn’t treat pain: reluctance to prescribe, poor assessment Poor staff knowledge: pain intensity < elderly, cognition issues Patient compliance

19. Workloads, staff inconsistency, limited time Lack of pain management protocols, tools Inadequate assessment and dosing Inadequate knowledge, misconceptions: fears of respiratory depression, side effects, drug interactions

20. Medical and paramedical staff tend to underestimate patients’ pain and therefore under-treat it. Pain is nearly always a manifestation of a pathologic process. Fear of opioid abuse often leads to inadequately treated pain Importance of Pain Assessment

21. Pain can lead to suffering and disability, especially among the work force. Acute pain is typically associated with a neuroendocrine response which is proportional to pain intensity and which affects postoperative outcome in many cases. Cognitively impaired patients are unable to report pain.

22. Children may be unable or unwilling to exhibit pain behavior or to report pain because of their age, developmental stage, mental or physical capacity, severity or chronic state of illness, emotional state, language or culture or fear of needles.

23. Classification of Pain ACUTE vs. CHRONIC NOCICEPTIVE vs. NEUROPATHIC SOMATIC vs. VISCERAL

24. A. Intensity of pain B. Site/Location C. Quality of pain: throbbing, burning, e.t.c. D. Pattern: onset, duration, frequency E. Aggravating/relieving factors F. Medication history G. Meaning of the pain H. Cultural factors I. Physical exam & functional assessment J. Laboratory/diagnostic evaluation PAIN Assessment

25. This mnemonic is devised to show the steps in pain assessment: LProvoking factors LQuality LRegion/Radiation LSeverity/Symptoms LTiming PQRST

26. Patient self-report, most valid measure of pain Involve family/caregiver in history-taking Open-ended questions before close- ended questions requiring yes/no response. -How would you describe your pain? (open-ended) - Is your pain burning? Is it throbbing? (close-ended) When did your pain start? - What kind of activities make your pain worse? Pain Interview

27. - What makes your pain better? - Tell me how your pain affects the way you function. - Tell me how your pain affects your life and family. - Describe where in your body you experience pain. (pain map)

28. Pain Map

29. Site: Patient may have multiple sites; some may be referred Total pain/existential distress: patient describes pain all over body. Assess for anxiety, depression etc Pattern: If always present = baseline pain; Breakthrough pain = intermittent and of greater intensity than former. Both occur in patients at the end of life Pain History (contd.)

30. Aggravating/relieving factors: May give away etiology of pain as well as potential tx. E.g. MSK pain and massage Medication: efficacy, possible side effects, herbal hx Meaning of pain to patient: ??Punishment, ?Affliction by enemies Cultural beliefs: Hausa-fulanis and pain

31. Physical Exam In Pain Assessment Inspection / Observation Overall impression. Facial expression: Grimacing; furrowed brow; appears anxious; flat affect Body position and spontaneous movement: there may be positioning to protect painful areas, limited movement due to pain Diaphoresis – can be caused by pain Areas of redness, swelling Atrophied muscles Gait Myoclonus – possibly indicating opioid-induced neurotoxicity “You can observe a lot just by watching” Yogi Berra Yogi Berra

32. Palpation: tenderness Auscultation: hyperactive bowel sounds = bowel obstruction Percussion: Rule out other added causes of pain e.g. gas accumulation in bowel Physical Exam (contd)

33. Pain assessment: Neurological Examination Important in evaluating pain, due to the possibility of spinal cord compression, and nerve root or peripheral nerve lesions Sensory examination –Areas of numbness / decreased sensation –Areas of increased sensitivity, such as allodynia or hyperalgesia Motor (strength) exam - caution if bony metastases (may fracture) Deep tendon reflexes – intensity, symmetry –Hyperreflexia and clonus: possible upper motor neuron lesion, such as spinal cord compression or cerebral metastases. –Hyoporeflexia - possible lower motor neuron impairment, including lesions of the cauda equina of the spinal cord or leptomeningeal metastases. Sacral reflexes – diminished rectal tone and absent anal reflexes may indicate cauda equina involvement of by tumour

34. Ability to perform self-care: groom, dress Walking: up and down stairs; presece or absence of falls Cooking: Able to hold pots; discern when things are hot Functional Assessment

35. Diagnostic/Lab evaluation: Rule out treatable causes e.g. X-ray for fracture ; abdominal ultrasound for ascites Reassessment: Changes in pain quality, changes in pain treatment modalities, pain relief. Pain charting: Make pain visible through documentation = 5 TH VITAL SIGN Others

36. A. SINGLE DIMENSION METHODS Visual analogue scale: Consists of a 10-cm line with two anchor points of ‘no pain’ and ‘worst pain imaginable’. Patients locate point on line that best describes their pain. Measurement of Pain

37. Advantage: Simple to use, can be translated into other languages, sensitive to small changes in pain report. Disadvantage: Cannot be used by visually impaired, young children and cognitively impaired adults.

38. Verbal rating scale: Has four points: no pain, mild pain, moderate pain, severe pain. Advantages: Easy to use, can be used by mildly cognitively impaired. Disadvantages: insensitive to small changes in pain intensity

39. The 5-point pain scale: A simple pain scale with similar advantages and disadvantages to VAS. Figure 1: Visual Analog Scale and 5-Point Pain Scale

40. McGill Pain questionnaire - designed by Melzack and team at McGill University, U.S.A in early 1970s. - Questions based on four domains viz affective, sensory, evaluative, miscellaneous. - Modified later to contain 15 words, a VAS and a pain intensity scale. Multidimensional Methods

41. Advantages: Evaluates mood, behavior, thoughts, belief, physiological effects and their interactions with each other. Helps the clinician treat all aspects of the pain experience. Disadvantages: Long and difficult questionnaire.

42. Depends on age of the child A. Self-report: For ages 2 years and older. Patients report pain but not intensity. B. Tools: Standardized tools like Hester’s Poker Chip tool can be used for ages 4 – 5 years. - Faces pain scale can also be used. - Ages 6 – 7 years can use VAS. Assessment of Pain in Children

43. Faces pain scale: used in non- verbal or young children less than 7 years. Children are asked to indicate their pain by pointing to one of the faces. E.g. Wong-Baker Faces pain rating scale.

44. Neonatal Infant Pain Scale (NIPS): Measures behavioural signs of pain including facial expression, cry, breathing patterns, movement of arms and legs and state of arousal. FLACC: Faces, leg, activity, cry, consolability. Used in infants between 2 months and 7 years with higher validity. May be used in neonates.

45. PAIN CONTROLPAIN CONTROL

46. Routes of administration Oral Intramuscular Intravenous (includes PCA) Epidural Rectal Topical Subcutaneous

47. Method that allows patient in pain administer their own pain relief. For intravenous method, electronically- controlled programmable pump delivers a fixed dose every time patient requests. Maximum hourly dose and lock-out interval prevents overdose (like ATMs with withdrawal limits). Nurse-controlled analgesia; Patient-controlled Analgesia

48. Administration of pain medicine into epidural space by intermittent boluses or infusion pump. Used in women in labour, terminally- ill, and for postop pain control. Advantage: little sedation, low risk of respiratory depression. Epidural Analgesia

49. Infusion of fluid through a fine needle into the tissues under the skin. Has little swelling or discomfort and medication absorbs well. Subcutaneous Infusion Pumps

50. PHARMACOLOGICAL THERAPIES NON-PHARMACOLOGICAL TECHNIQUES Treatment of Pain

51. A. Opioid Analgesics: a.k.a. Narcotic analgesics orMay be opiates (derived from the opium poppy) or opiate-like (semi-synthetic or synthetic opioids) Uses: Moderate to severe pain Examples: Opiates:- Morphine, Heroin, Codeine, Pethedine(Meperidine) Opiate-like:- Tramadol, Fentanyl, Pentazocine, Methadone PHARMACOLOGICAL THERAPIES

52. Mechanism of action: Block opioid receptors, preventing action of neurotransmitters at that site Adverse effects: Constipation, respiratory depression, sedation, urinary retention, nausea/vomiting, pruritus Consider opioid reversal in unrousable patient with low respiratory rate and poor oxygenation = naloxone

53. Non-opioids B. Non-opioid Analgesics: Core analgesics and adjuvants Uses: mild pain, anti-inflammatory pain Examples of core analgesics: Aspirin, Acetaminophen, Ibuprofen, Diclofenac E.g. adjuvants: Antidepressants and anticonvulsants, local anaesthetics, corticosteroids

54. Paracetamol: antipyretic, analgesic. Can cause liver dysfunction with doses >4000mg/day NSAIDS: analgesic, antipyretic, anti- inflammatory e.g. aspirin, ibuprofen. Inhibit prostaglandin y blocking cyclooxygenase enzyme. Adverse effects of gastric irritation, bleeding from platelet aggregation inhibiton and renal dysfunction in dehydrated patients.

55. Used in perioperative and postoperative pain. Application Infiltration of surgical site Direct nerve blocks Regional Infiltration Intra-articular infiltration Epidurals Mainly used – Lidocaine & Bupivacaine. Local Anaesthetics

56. Adjuvants Used In Palliative Care General / Non-specific –corticosteroids –cannabinoids (not yet commonly used for pain) Neuropathic Pain –gabapentin –antidepressants –ketamine –topiramate –clonidine Bone Pain –bisphosphonates –(calcitonin)

57. SEVERE PAIN: Keep giving mild pain medication and add a strong opioid such as morphine or Fentanyl MODERATE PAIN: Keep giving mild pain medication and add a mild Opioid such as codeine MILD PAIN: Aspirin, ibuprophen Acetominophen, naprosyn WHO Pain Ladder

58. Concepts of WHO Pain Ladder By the mouth By the clock By the ladder For the individual With attention to detail

59. TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the same effect

60. PHYSICAL DEPENDENCE A normal physiological phenomenon in which a withdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered

61. PSYCHOLOGICAL DEPENDENCE and ADDICTION A pattern of drug use characterized by a continued craving for an opioid which is manifest as compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drug

62. 1.Keep patient clean & dry. 2.Keep the patient warm. 3.Room with moderate temperature and humidity. 4.Well padded place to sleep. 5.Patients surrounding should be pleasant & quiet. 6.Human contact 7.Acupressure, acupuncture, massage, manipulation stimulate A-beta nerve fibers. Non pharmacologic approach

63. Cryotherapy Thermotherapy Actinotherapy Ultrasound therapy Low Level Laser Therapy (LLLT) Transcutaneous Electrical Neuro- stimulation (TENS) Distraction, Relaxation.

64. Summary of Pain Assessment in Palliative Care 1.Thorough assessment by skilled and knowledgeable clinician –History –Physical Examination 2.Pause here - discuss with patient/family the goals of care, hopes, expectations, anticipated course of illness. This will influence consideration of investigations and interventions 3.Investigations – X-Ray, CT, MRI, etc - if they will affect approach to care 4.Treatments – pharmacological and non- pharmacological; interventional analgesia (e.g.. Spinal) 5.Ongoing reassessment and review of options, goals, expectations, etc.

65. THANK YOU