1. Dr Jonathan Riordan Consultant in Palliative Medicine St Clare Hospice
Pain Management
Dr Jonathan Riordan
Consultant in Palliative Medicine
St Clare Hospice

3. Objectives Introduction to pain and why it is important
Pathophysiology of pain
General principles of pain management
Opioids and adjuncts

4. Pain

5. What is pain – the scientific definition
“unpleasant sensory and emotional experience associated with actual or potential tissue damage” (Merksey 1979)

6. BUT…
Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life.
Pain is unquestionably a sensation in part or parts of the body but is also unpleasant and therefore an emotional experience.

7. And So… Pain is a complex
A physiological and emotional experience - not a simple sensation
It is a subjective feeling, rather than objective

8. Why is pain important?

9. Why is pain important?
National UK statistics indicate that pain or discomfort was reported by ½ of those >65 years
This figure increases to 45-83% of institutionalised older people

10. ¾ of cancer patients experience pain

11. Cancer versus non-cancer1.
Pain
35-96% 2.
Confusion
6-93% 3.
Anorexia
30-92% 4.
Fatigue
32-90% 5.
Anxiety/Depression
3-79% 6.
Dyspnoea
10-70% 7.
Insomnia
9-69% 8.
Nausea
6-68% 1.
Dyspnoea
60-88% 2.
Fatigue
69-82% 3.
Pain
41-77% 4.
Anxiety/Depression
9-49% 5.
Insomnia
36-48% 6.
Nausea
17-48% 7.
Constipation
38-42% 8.
Anorexia
21-41%
Cancer
Heart Failure

12. Objectives Introduction to pain and why it is important
Pathophysiology of pain
General principles of pain management
Opioids and adjuncts

13. Objectives Introduction to pain and why it is important
Pathophysiology of pain
General principles of pain management
Opioids and adjuncts

14. Pathophysiology of Pain

15. Pain pathway
Whenwe encounter a painful stimulus, signals are carried to the brain via receptors (termed nociceptors) which connect to nerve fibres which carry the sensation of pain to the dorsal horn. These signals then cross the spinal cord and are transmitted to the brain in the Spinothalamic Tract (STT).

16. Objectives Introduction to pain and why it is important
Pathophysiology of pain
General principles of pain management
Opioids and adjuncts

17. Objectives Introduction to pain and why it is important
Pathophysiology of pain
General principles of pain management
Opioids and adjuncts

18. General Principles of Pain Management

19. Assessing pain
Remember pain is a subjective feeling. It is what the patient says it is...
But, try and assess using:
clinical acumen
pain scores
specific pain assessment tools

21. Begin by assessing the physical pain...
S – site (?more than one site) – record on body map
O – onset
C – character (descriptive terms e.g. aching/burning)
R – radiations
A – alleviating factors
T – time course
E – exacerbating factors
S – severity

23. Cognitively impaired Patients
Increasing amount of work looking at specialist palliative care needs of dementia patients
Estimated that 1/3 will die with dementia by 2050
Often a challenge to assess their level of discomfort

24. Cognitively impaired Patients
Important to involve carers (or those who know patient best)
Take your time
Advocate the use of observational behavioural measurement tools
Numerous pain assessment/measurement tools available

25. Scores things such as vocalisation, facial expression, body language to assess for pain.

26. Treating of pain…

27. WHO Pain Ladder Begin with simple analgesics
If maximal dose Step 1 drugs are not working, move up the ladder to Step 2
Good practice suggests continuing with Step 1 drugs when commencing Step 2 drugs
If pain not controlled, move up the ladder to Step 3

28. General Principles of Pain Management
Treat constant pain with regular analgesia:
By mouth
By the clock e.g. 4/6/12 hourly
By the “Ladder”
Different pain types respond to different analgesics
Don’t forget impact of psychosocial factors e.g. depression & anxiety on expression of pain

30. Dame Cicely Saunders

31. “Total Pain” Dame Cicely Saunders coined the term ‘‘total pain’’
Suggested that pain can be understood as having physical, psychological, social, emotional, and spiritual components.
The combination of these elements is believed to result in a ‘‘total pain’’ experience that is individualized and specific to each patient's particular situation.
Effective pain relief follows the acknowledgment and management of the physical, psychological, social, and spiritual dimensions

32. Objectives Introduction to pain and why it is important
Pathophysiology of pain
General principles of pain management
Opioids and adjuncts

33. Objectives Introduction to pain and why it is important
Pathophysiology of pain
General principles of pain management
Opioids and adjuncts

34. Opioids

35. A number of strong opioids are licensed in the UK, however for pain relief in palliative care a relatively small number are commonly used.
For example, NICE guidelines mainly focus on:
Codeine Buprenorphine
Morphine Fentanyl
Oxycodone Alfentanil

36. How do you choose between opioids?
No evidence to suggest one strong opioid is more efficacious than another
Use is governed by:
Adverse effect profile and pharmacokinetics/dynamics of opioid
Individual patient

37. Inter-individual Response to Opioids
Disease
Clinical Response to Opioid
Age
Diet
Social
Genetics
Other Drugs
Psychological

38. Codeine Most commonly used step 2 in UK
Metabolised to morphine in liver
Genetic variation in ability to metabolise to morphine
Poor metabolisers 10% Caucasians (ineffective analgesic)
Ultra-rapid metabolisers 3 – 6% Caucasians (enhanced analgesia/side effects)
Codeine is 10 x weaker than morphine for most people

39. Morphine
Remains gold standard choice for moderate to severe cancer pain
Strong agonist at  receptor
Should be avoided in renal failure where possible

40. Morphine Dose is titrated according to effect:
No standard dose
No ceiling dose
Large dose variations between individuals
With proper administration
70 – 90% will get adequate pain relief

41. Morphine Immediate release preparations:
Oramorph 10mg/5ml liquid and 20mg/ml concentrate
Sevredol tablets
Modified release preparations (12hrly):
MST MR tablets
Zomorph capsules/MST granules (PEGs)
Subcutaneous preparations

42. Oral Morphine Dose Titration (opioid naive):
Short acting IR formula e.g 2.5mg – 5mg oramorph
Given PRN when pain occurs
After hours assess requirement and switch to maintenance dose of MR preparation
Continue to offer PRN IR preparation for “breakthrough” pain.
Increase maintenance dose is needed
Give orally where possible

44. Breakthrough Doses “PRN”
Usually 1/6th of total opioid dose/24 hrs
30mg bd MST MR – 10mg oramorph IR breakthrough

45. Example… If patient required 6 doses of 5mg oramorph in 24 hours
= 30mg morphine in 24 hours
= 15mg BD MST
PRN dose would be 1/6th of this dose
= 5mg oramorph PRN

46. Oxycodone Synthetic opioid Similar titration to morphine
Oxynorm/Shortec IR: liquid/capsules
Oxycontin/Longtec MR: 12 hourly tablets
Subcutaneous preparation
?lower incidence of side effects than morphine, consider in those unable to tolerate morphine
Possibly “safe” in mild renal failure but may still have to dose reduce
Twice as strong as morphine (E.g. If on 60mg BD of morphine then would only need 30mg BD oxycodone

47. Patches - Fentanyl Dysphagia/tablet phobia Less constipating
Safe in renal failure (inactive metabolites)
Patch change every 72 hours

48. But… Not suitable for: Unstable pain Opioid naïve patients
Up to 12 hours to reach therapeutic dose
Steady state hours
Washout period 24 hours
Opioid naïve patients
Even starting dose is high
Patients with pyrexia
Increased absorption

49. NMDA receptor blockers
Analgesics
Non Opioids
Paracetamol
NSAIDs
Opioids
Weak e.g. Codeine
Strong e.g. Morphine
Adjuvants
Corticosteroids
Antidepressants
Anti-epileptics
NMDA receptor blockers
Muscle relaxants
Bisphosphonate
Adjuvants are drugs which are not primarily marketed for pain and in relation to analgesic efficacy are often circumstance specific. Term can be misleading as in many situations adjuvants alone can provide pain relief and reduction in undesirable effects

50. Specific Pains and Treatments
Bone pain
Bisphosphonates, Radiotherapy, NSAIDs, corticosteroids
Liver capsule pain
Paracetamol, NSAIDs, corticosteroids
Bowel colic
Anti-spasmodics e.g. Hyoscine butylbromide

51. Specific Pains and Treatments
Raised ICP
Corticosteroids, RT
Neuropathic pain
Adjuvants e.g. Amitriptyline, gabapentin, pregabalin
Incident pain e.g quick-acting, short-lived analgesics e.g. Abstral (sublingual fentanyl)

52. Objectives Introduction to pain and why it is important
Pathophysiology of pain
General principles of pain management
Opioids and adjuncts

53. Objectives Introduction to pain and why it is important
Pathophysiology of pain
General principles of pain management
Opioids and adjuncts

54. In Summary… The nature of pain is complex
It is important for us to have a good understanding of it
Management is based on a good assessment

55. In Summary…
Using the WHO ladder and the appropriate adjuncts we should expect to get on top of the majority of people’s pain
Don’t forget to address the non-physical aspects

56. Thank you for listening