1. Analgesic Trade Secrets
Dr Hannah Gunn
Consultant in Palliative Medicine
Northumbria Healthcare & Marie Curie Hospice Newcastle

2. Session Outline Defining pain Types of pain WHO Analgesic Ladder
Noceceptive
Neuropathic
Total
WHO Analgesic Ladder
Adjuvants
Case histories

3. Defining Pain

4. What is pain?

5. What is pain?
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
International Association for the Study of Pain (IASP) 1986

6. What is pain? Pain is what the patient says hurts
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
International Association for the Study of Pain (IASP) 1986
Pain is what the patient says hurts

7. Types of Pain

8. Types of Pain
Nociceptive Pain
Neuropathic Pain

9. Types of Pain Nociceptive Pain Neuropathic Pain
Transmitted by undamaged nervous system
Opioid receptors involved
Impulse  spinal cord  higher centres
WHO analgesic ladder
Neuropathic Pain
Transmitted by damaged nervous system
Partial opioid sensitive
Associated with hyperalgesia and allodynia
WHO analgesic ladder
Adjuvants

10. Total Pain

11. Total Pain Psycho-logical Spiritual Social Physical Total Pain
Financial
Spiritual
Social
Physical
Emotional

12. Total Pain Psycho-logical Spiritual Social Physical Total Pain
Financial
Spiritual
Social
Physical
Emotional

13. Pain Management Strategy

14. Pain Management Strategy
Modify pathological process
Surgery
Radiotherapy
Chemotherapy
Choose an analgesic
WHO analgesic ladder
Adjuvants
Side effects
Non-drug management of pain
Address all the domains of total pain
Heat pads, TENS
Lifestyle modification
Home equipment
Walking aides
Care package

15. WHO analgesic ladder

16. Choice of drug based on severity of pain
3.Strong opioid
2.Mild/ Moderate
opioid
1.Paracetamol
+/- NSAID
Choice of drug based on severity of pain
NOT on stage of disease

17. Adjuvants

18. When is an analgesic not an analgesic?
Ketamine
Methadone
Anti-spasmodic
When it’s an adjuvant!
Steroid
Anti-epileptic
Bisphosphonate
Muscle relaxants
Anti-depressant

19. Choice of drug based on severity of pain
3.Strong opioid
2.Mild/ Moderate
opioid
1.Paracetamol
+/- NSAID
Adjuvant Drugs
Adjuvant Drugs
Choice of drug based on severity of pain
NOT on stage of disease

20. Common Adjuvants Raised intracranial pressure Corticosteroids
Nerve compression
Liver capsule pain
Soft tissue infiltration
Neuropathic pain
(including tenesmoid pain)
Anti-depressants (eg amitriptyline) & Anti-convulsants ( eg. Gabapentin)
Colic
Antispasmodic ( eg buscopan)
Muscle cramp/spasm
Muscle relaxants (eg baclofen)
Bone pain
Bisphosphonates

21. Case 1 Joan, 63 year old woman
Diagnosed with left breast cancer 2 years ago
Mastectomy
Radiotherapy and chemotherapy
Ongoing hormone therapy
Presents to GP with RUQ pain, worse on inspiration, ‘like I’ve pulled a muscle’
Some vomiting, especially later in day, large volumes, hiccoughs and belching

22. Liver Capsule Pain Aetiology Presentation Management Liver metastases
RUQ pain
Stretch quality
Can vary with respiration
Management
Dexamethasone 8-16mg mane with PPi cover

23. Case 2 Brian, 74 year old man 8 year history of prostate cancer
Admitted with severe lower back pain, increasing for last few weeks, now unable to walk due to pain

24. SPINAL CORD COMPRESSION

25. Paracetamol and NSAID and morphine
Bone Pain
Paracetamol and NSAID and morphine
Aetiology
Bone infiltration
Pathological fractures
Presentation
Severe pain
Associated with site of metastases
Management
WHO analgesic ladder
Adjuvant analgesics
Dexamethasome 8-16mg mane with PPi cover
Bisphosphonate infusion
Gabapentin or amitriptyline

26. Summary

27. Pain is what the patient says hurts
WHO analgesic ladder
Adjuvants
Review, review, review

28. Pain is what the patient says hurts
WHO analgesic ladder
Adjuvants
Review, review, review
Ask your friendly neighbourhood palliative care team!

29. Thank You!