1. Pain and Symptom Management
Fran MacIvor
Locum Consultant, Palliative Medicine

2. Pain basics, and a little bit about nausea and constipation

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

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

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

7. Visual pain scales

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

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

11. Initiating Step 3 - Opiates
Initiating Opiates

12. 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

13. 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

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

15. 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?

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

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

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

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

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

22. Causes of nausea and vomiting

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

24. 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

25. Help with symptoms HPCT (Tay-UHB.palliative@nhs.net)
Palliativedrugs.com