1. Pain management in palliative care 2
Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

2. Outline Overview of day 1 – 5mins
Prescribing opioid analgesics mins
Breakthrough, emergency, and incident pain
Side effects and toxicity of analgesics
Addiction and dependence
Dispelling some myths
MKF 2016

3. Overview of palliative care
Total Care
Continuum of Care

4. Dame Cicely Saunders Concept of Total Pain
Physical
Spiritual
Psychological
Social
Total Pain
Dame Cicely Saunders Concept of Total Pain
MKF 2016

5. Presentation/Diagnosis
Traditional Model of Care
Curative Care
Hospice
Presentation/Diagnosis
Death
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6. Palliative Care in the Continuum
Diagnosis
Death
HEALTH
ILLNESS
DEATH
Curative & Life Prolonging Care
Palliative Care
Symptom
Management
Life
Closure
EOL/
Dying
Prevention
Bereavement
CURATIVE CARE
HOSPICE CARE
MKF 2016

7. Overview of pain management – day 1
ECG of pain
Mechanism of pain
Types of pain
WHO analgesic ladder

8. Pain Assessment . . . Symptom Assessment – PQRST strategy
What Provokes or Palliates the pain?
What is the Quality of the pain?
What Regions are involved, and does it Radiate?
What is the Severity of the pain (0 – 10 scale)?
What is the Timing of the pain?
Detailed pain medication and treatment history
Prior opioid (prescription or not) and substance use
MKF 2016

9. Pain Terminology Pain Type Features Examples Nociceptive (somatic)
Sharp, aching, stabbing pain
Localized, acute or chronic
Musculoskeletal injury
Bone pain (fractures, mets)
Neuropathic
Burning, shooting, ‘electric’ pain
Radiates, often chronic
Diabetic neuropathy
Post-herpetic neuralgia
Visceral
Gnawing, crescendo pain
Poorly localized
Bowel obstruction
Angina
MKF 2016

10. WHO Analgesic Ladder: adults
Step 3
Strong opioid
Step 2
Weak opioid
Step up if pain persists or increases
Severe pain
Step up if pain persists or increases
Step 1 Non-opioid
Moderate pain
+/- non-opioid +/- adjuvant
Mild pain
+/- non-opioid +/- adjuvant
+/- adjuvant
Consider prophylactic laxatives to avoid constipation
Non-opioids ibuprofen or other NSAID, paracetamol (acetaminophen), or aspirin
Weak opioids codeine, tramadol, or low-dose morphine
Strong opioids morphine, fentanyl, oxycodone, hydromorphone, buprenorphine
Adjuvants antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid
Combining an opioid and non-opioid is effective, but do not combine drugs of the same class.
Time doses based on drug half-life (“dose by the clock”); do not wait for pain to recur 10
Adapted by Treat the Pain from World Health Organization (accessed 7 November 2013)

11. Practical Assessment
Esther, a 28 year-old woman with cancer, reports a pain score of 5 out of 10. Which medicines would you consider prescribing? A. Codeine B. Tramadol C. Low-dose morphine D. Any of the above If you prescribe low-dose morphine, what is Esther’s starting dose? 2.5mg every four hours What other prescriptions must be written at the same time? Laxatives
MKF 2016

12. MKF 2016

13. Prescribing opioid analgesics 1
Practicals

14. Opioid Pharmacokinetics
Dosing – First Order Kinetics
Opioids
tCmax
t1/2 IV
15 mins
4 Hours
SC / IM
30 mins
PO / PR
60 mins
Changing Routes of Administration
PO / PR
IV / SC / IM
Epidural
Intrathecal 3 1
0.1
0.01
MKF 2016

15. MKF 2016

16. Breakthrough, emergency, and incident pain
Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

17. Objectives
Define breakthrough pain and learn how to use rescue doses to treat it
Learn how to adjust daily doses of opioids based on rescue dose requirements
Learn how to diagnose a pain emergency and how to treat it
Define and outline treatment for incident or procedural pain
Define and outline treatment for end-of-dose failure
MKF 2016

18. Breakthrough pain
Breakthrough pain: a sudden, temporary flare of severe pain that occurs on a background of otherwise controlled pain
May be more common during first three days of treatment as morphine dose is titrated from starting dose to effective dose
MKF 2016

19. Breakthrough pain
50-70% of patients with chronic cancer-related pain also experience episodes of breakthrough pain
Associated with greater pain-related functional impairment, worse mood, and more anxiety
Healthcare providers routinely under-diagnose and under- treat breakthrough pain
MKF 2016

20. Diagnostic criteria Stable analgesic regimen in the previous 48 hours
Presence of controlled background pain in the previous 24 hours (i.e. average pain score <5 out of 10)
Temporary flare of severe or excruciating pain in the previous 24 hours
MKF 2016

21. Rescue dose
Rescue dose: a dose of immediate-release morphine that is the same as the dose given every 4 hours and can be given as often as required to treat breakthrough pain
Note these in the patient chart
Write orders that include rescue doses
MKF 2016

22. Breakthrough pain and rescue doses
Rescue dose should be administered at the first sign of breakthrough pain
Pain that is allowed to build up is harder to control
When you give a rescue dose of morphine to treat breakthrough pain you should still give the next regular dose on schedule
The rescue dose must be increased whenever the regular dose is increased
Rescue dosing is suitable for all immediate-release opioids, not just morphine
MKF 2016

23. Adjusting the background dose
A frequency of 4 or fewer rescue doses per day is normal
If a patient requires more than 4 rescue doses per day, you should increase the background dose
Add total rescue doses to normal daily dose and divide by 6
Example: in a patient taking 10mg every 4 hours and 5 rescue doses of 10mg, new daily dose is (10*6)+(10*5)=110mg, given as 15 or 20mg every 4 hours
If there is no need for rescue doses, you may try a small reduction in background dose
MKF 2016

24. Pain emergency
The goal is to control pain (i.e. to get pain score below 5 out of 10)
If patient is in excruciating pain (pain score=9 or 10), it is considered a pain emergency
Administer rescue dose intravenously (IV)
Remember to convert oral dose to IV dose by dividing by 2- 3
Otherwise rescue doses can be oral
Wait for dose to take effect (10 minutes for IV and 30 minutes for oral) and then reassess
Repeat dose if pain score is 5 or higher
MKF 2016

25. Spinal cord compression
Spinal cord compression can cause severe pain
Treat with dexamethasone 16-24mg per day
In a pain emergency, may treat with IV dexamethasone: initial dose up to 100mg, followed by 60mg in three divided doses
Continue dexamethasone until other treatment is started (radiotherapy or drug therapy), then taper off gradually
MKF 2016

26. Respiratory depression
Pain is an antagonist for all depressing effects of opioids
As long as the pain and the opioid dose are balanced, there will only be tolerable sedation and no respiratory depression
That is why the goal of titration is to get to tolerable pain level (pain score <5 out of 10), not to get to no pain (pain score=0)
MKF 2016

27. Incident pain and end-of-dose failure
Types of pain that are similar to breakthrough pain
Incident pain
End-of-dose failure
MKF 2016

28. Incident or procedural pain
Incident or procedural pain: Pain precipitated by a particular activity or procedure, such as dressing change, washing, change in position, eating, or disimpaction
Can be anticipated
Supplement regular analgesic regimen with a rescue dose given minutes before the activity
MKF 2016

29. End-of-dose failure
End-of-dose failure: Effect of analgesia wears off after a few hours and pain returns
Treatment
Change to a longer-acting medicine
Increase the dose of the current medicine
Reduce the dosing interval
MKF 2016

30. Prescribing opioid analgesics 2
Practical

31. Take home messages
Breakthrough pain may require rescue doses that are determined by the patient’s pain, in addition to regular pain treatment
The goal of treating pain emergencies is to control pain
Respiratory depression can be prevented with the proper balance of pain and opioid doses
Rescue doses given before painful procedures or activities can reduce the pain they cause
MKF 2016

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33. Side effects and toxicity of analgesics
Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

34. Objectives
Discuss side effects of Step 1, Step 2, and Step 3 analgesics
Review signs of opioid toxicity
Describe treatment options of opioid toxicity
MKF 2016

35. Step 1 analgesics: paracetamol
Hepatotoxicity can occur if more than the maximum dose (4g) is given per day
Alcohol-dependent and undernourished patients are at a higher risk
Contraindications:
Severe hepatic and renal impairment, alcohol dependence, undernourishment, and glucose-6-phosphate dehydrogenase deficiency
MKF 2016

36. Step 1 analgesics: NSAIDs
Side effects are usually seen with longer-term use (>7 days)
Gastro-intestinal (GI) bleeding
If any GI symptoms develop (dypepsia, epigastric pain), stop and give H2 receptor antagonist, e.g. Ranitidine
Renal failure
Contraindications
Gastrointestinal ulceration, hemophilia, hypersensitivity to aspirin, thrombocytopenia, young children, pregnancy (especially third trimester), breastfeeding, and advanced renal impairment
MKF 2016

37. Step 2 analgesics: weak opioids
Weak opioids are considered very safe, even in patients with impaired organ function
Codeine
Give laxatives to avoid constipation unless patient has diarrhoea
Tramadol
Use with caution in epileptic patients, especially if patient is on other drugs that lower the seizure threshold
May cause serotonin syndrome in patients on other serotonergic medications
MKF 2016

38. Step 3 analgesic: morphine
When used correctly, problems like dependency, addiction, tolerance, and respiratory depression are rare
Opioids are not toxic to any organ
No contraindications except history of allergic reactions (rare)
MKF 2016

39. Step 3 analgesic: morphine
Constipation is a very common side effect of all opioids and does not resolve spontaneously
Laxatives should be prescribed as prophylaxis unless patient has diarrhoea
Treat with a stimulant laxative
i.e. Bisacodyl 5mg at night, increasing to 15mg if needed
MKF 2016

40. Step 3 analgesic: morphine
Nausea and vomiting
Usually mild and resolves within one week
Anti-emetics (metoclopramide or haloperidol) can be given for the first few days of treatment
Metoclopromide 10mg every 8 hours or haloperidol 1.5mg once a day
Itching
Less common
Treat with chlorpheniramine
MKF 2016

41. Step 3 analgesic: morphine
Drowsiness
Usually resolves within one week
Advise patients not to perform dangerous tasks or operate heavy machinery for 2 weeks while they adjust to the medications
Patients who have been unable to sleep well due to pain may initially sleep for long periods once their pain has been relieved
These patients should be easily arousable
If it does not improve, reduce the morphine dose
MKF 2016

42. Step 3 analgesic: morphine
Hepatic and renal impairment
Not a contraindication for use
Titrate slowly and carefully to avoid accumulation of medication or active metabolites
Consider increasing interval between doses to 6, 8, or even 12 hours
Elderly
Older people respond well to lower doses
Consider reducing the dose or increasing the dosing interval to minimize side effects
MKF 2016

43. Opioid toxicity
Toxic effects of opioids are rare when they are used in appropriate doses
Signs include
Drowsiness that does not improve
Confusion
Hallucinations
Myoclonus (abrupt spasms or muscle twitching)
Respiratory depression (slow breathing)
Pinpoint pupils
MKF 2016

44. Opioid toxicity
If you are concerned that a patient is experiencing toxicity, reduce the dose by 50% and consider giving parenteral fluids to increase excretion
In severe cases, stop the opioid and give Naloxone, an opioid antagonist
Naloxone is rarely used and should be used with caution as it will precipitate pain crisis
Haloperidol 1.5-5mg at night may help with any hallucinations or confusion
Be sure to rule out other causes (such as urinary tract infection, hypoxia, or side effect of another medication)
MKF 2016

45. Take home messages
The use of opioids can cause side effects; with proper use these side effects can be mediated
When using opioids, give laxatives to avoid constipation unless patient has diarrhoea
When used correctly, patients don’t become dependent or addicted on morphine
Opioids are not toxic to any organ
MKF 2016

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47. Addiction and dependence
Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions.

48. Objectives Discuss the difference between addiction and dependence
Review withdrawal, pseudoaddiction, and tolerance
MKF 2016

49. Research in the last decade has shown…
Risk of developing addictive behaviors as a consequence of medical use of opioids for chronic cancer pain is low
Patients, family members, and healthcare workers commonly overestimate the risk of addiction
Patients, family members, and healthcare workers often confuse physical dependence and addiction
Together, these concerns contribute substantially to physician reluctance or unwillingness to prescribe opioids and patient reluctance to use them
MKF 2016

50. So, what are the rates of addiction?
What proportion of patients using opioids to manage chronic cancer pain will become addicted to opioids?
A. 40%
B. 25%
C. <10%
D. <1%
E. <0.5%
MKF 2016

51. Risk of addiction in medical use of opioids
The correct answer is E: less than one-half of 1 percent
According to the World Health Organization:
A systematic review of research papers concludes that only 0.43% of patients with no previous history of substance abuse treated with opioid analgesics to relieve pain abused their medication and only 0.05% developed dependence syndrome
Fishbain et al (2008): Among chronic pain patients with no history of opioid abuse/addiction, incidence of abuse/addiction is 0.19%
MKF 2016

52. Defining addiction and dependence
Addiction: Psychological dependence leading to craving, impaired control over drug use, and compulsive use to get psychic effects despite harm
Behaviours associated with addiction
Compulsive drug-seeking
Unauthorized use or dose escalation
Use despite harm to self or others
MKF 2016

53. Dependence
Dependence: The phenomenon of withdrawal when an opioid is abruptly discontinued
Physical dependence is a normal response to chronic therapy
Prevent withdrawal by titrating the opioid dose down slowly
Reduce daily dose by 25% each day
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54. Withdrawal Signs and symptoms of withdrawal Anxiety Nervousness
Irritability
Alternating chills and hot flushes
Wetness: salivation, watery eyes, runny nose, sneezing, sweating, and gooseflesh
At peak intensity of withdrawal, patients may experience:
Nausea and vomiting
Abdominal cramps
Insomnia
Multifocal myoclonus or abrupt spasms (rare)
MKF 2016

55. Pseudoaddiction
When the dose of opioids is not enough to relieve pain, some patients may become anxious about opioid availability and may demonstrate some behaviours that you see in patients with addiction, such as
Asking for the next dose before it is due
Taking medications not prescribed to them
Taking illegal drugs
Using deception to obtain medications
MKF 2016

56. Pseudoaddiction
These behaviours go away after the dose has been increased and pain has been relieved
It is important to distinguish pseudoaddiction from addiction: patients with pseudoaddiction stop seeking medications once their pain has been effectively treated
MKF 2016

57. Tolerance
Tolerance
Decreasing response to a drug as a consequence of its continued use
An increased dose is required to achieve a similar effect
Tolerance to opioids is not common
Increases in opioid requirements are usually related to disease progression
MKF 2016

58. Take home messages
Risk of developing addictive behaviors as a consequence of medical use of opioids for chronic cancer pain is low
The risk of addiction is commonly overestimated by patients, family and healthcare workers alike
Healthcare workers should be able to distinguish pseudoaddictive behaviors from addictive behaviours
When discontinuing morphine, avoid symptoms of withdrawal by titrating the opioid dose down slowly
MKF 2016

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60. Dispelling some myths Myth: Children don’t feel pain
There is no evidence that neonates or young children feel less pain than adults
Myth: Moderate or severe pain is uncommon
Approximately 50% of people with advanced HIV and 80% of people with advanced cancer will experience moderate or severe pain
Other causes of pain include surgery, trauma, burns, myocardial infarction, sickle cell disease, and childbirth
MKF 2016

61. Dispelling some myths Myth: Opioids are dangerous
According to the World Health Organization:
“Opioid analgesics, if prescribed in accordance with established dosage regimens, are known to be safe and there is no need to fear accidental death or dependence.”
“A systematic review of research papers concludes that only 0.43% of patients with no previous history of substance abuse treated with opioid analgesics to relieve pain abused their medication and only 0.05% developed dependence syndrome.”
MKF 2016

62. Dispelling some myths Myth: Pain relief is not affordable
Locally produced oral morphine solution costs just USD per week in Uganda and 5.00 USD per week in Nigeria
Tablets or injectable opioids may be more expensive
Myth: Morphine is only appropriate for patients at the end of life
Morphine allows many patients who are not dying, but are limited by pain, to live a more active life
Pain treatment should be determined by the level and type of pain, not the stage of disease
MKF 2016

63. Thank you Palliative Care Team
MKF 2016