1. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Unit 11 Palliative Care Part 1: Pain Management

2. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Learning Objectives Discuss the approach to relief of symptoms during the course of HIV infection Describe the stepped approach to pain control and the use of analgesics Unit 11 Part 1: Palliative care, Pain Management Slide 2

3. Training on Clinical Care of HIV, AIDS and Opportunistic Infections WHO Definition of Palliative Care An approach that improves the quality of life of patients and their families facing the problems associated with life- threatening illnesses, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems—physical, psychological and spiritual (WHO, 2002) Unit 11 Part 1: Palliative care, Pain Management Slide 3

4. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Definition of Pain An unpleasant sensory and emotional experience often associated with actual or potential tissue damage or described in terms of such damage. Adapted from international Association for the Study of Pain Unit 11 Part 1: Palliative care, Pain Management Slide 4

5. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Types of Pain Nociceptive Related to tissue injury or tissue stress Neuropathic Produced by nerves themselves Intestinal Colic Nociceptive, but worsened by opioids Bone pain May not respond to opioids Unit 11 Part 1: Palliative care, Pain Management Slide 5

6. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Pain as a Symptom of a Treatable Condition Headache Chest pain Pharyngeal or retrosternal pain Abdominal pain Skin pain Leg pain (neuropathy) Generalised pain Unit 11 Part 1: Palliative care, Pain Management Slide 6

7. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Causes of Headache Tension headache Febrile illness Malaria Sinusitis With focal abnormalities Brain mass lesion like toxoplasmosis or tuberculoma Acute Meningitis Pneumococcus, Meningococcus Chronic Meningitis Cryptococcus and TB Unit 11 Part 1: Palliative care, Pain Management Slide 7

8. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Causes of Chest Pain With cough or dyspnea Pneumonia Tuberculosis Substernal pain not associated with swallowing Mediastinal adenopathy or disease TB, KS Pericarditis TB Pain on swallowing See retrosternal pain Unit 11 Part 1: Palliative care, Pain Management Slide 8

9. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Pharyngeal or Retrosternal Pain Oropharyngeal Tonsillitis/pharyngitis Oral candidiasis Herpes simplex Aphthous ulcers Kaposi’s Sarcoma Gingivitis Oesophageal Acid reflux Candidiasis CMV or HSV Aphthous ulcers Kaposi’s Sarcoma Unit 11 Part 1: Palliative care, Pain Management Slide 9

10. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Abdominal Pain Upper GI tract Dyspepsia Gastric or peptic ulcer disease Enterocolitis/Diarrhea Intestinal parasites Bacterial dysentery Clostridium difficile TB, MOTT and CMV Biliary Tract Disease Opportunistic agents of enterocolitis Abdominal masses Peritonitis (TB) Abscess KS and lymphoma Unit 11 Part 1: Palliative care, Pain Management Slide 10

11. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Skin Pain Herpes (Varicella) Zoster Post-herpetic neuralgia Skin infections Impetigo and pyoderma Folliculitis Cellulitis Unit 11 Part 1: Palliative care, Pain Management Slide 11

12. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Leg pain Neuropathy HIV Medications d4T, ddI INH Vitamin deficiency Post-Herpetic neuralgia Diabetes Poor circulation Localized infections Venous thrombosis Unit 11 Part 1: Palliative care, Pain Management Slide 12

13. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Generalised Pain Fever Bed-ridden status Rheumatism Non-specific etiology Unit 11 Part 1: Palliative care, Pain Management Slide 13

14. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Relationship Between Specific Treatment and Symptom Relief Specific Treatment Symptom Relief Initial Diagnosis Evolution of the illness Death Passage of time Unit 11 Part 1: Palliative care, Pain Management Slide 14

15. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Stepped Approach to Analgesic Therapy Mild Pain Non-narcotic Moderate Pain Weak opioids Severe Pain Strong opioids Unit 11 Part 1: Palliative care, Pain Management Slide 15

16. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Stepped Approach to Analgesic Therapy DrugDosage Mild Pain Aspirin Paracetamol Ibuprofen 600 mg q 4 hrs 1 g q 4 hrs 200-400 mg q 8 hrs Moderate Pain Codeine Tramadol 60 mg q 4 hrs 50-100 mg q 4-6 hrs Severe pain Oral or injectable opioids, morphineMinimum 5 mg q 4 hrs, no maximum Unit 11 Part 1: Palliative care, Pain Management Slide 16

17. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Stepped Approach to Analgesic Therapy For moderate to severe pain, can combine a non-narcotic (aspirin, paracetemol) with an opioid Never combine a weak opioid (codeine) with a strong opioid (morphine) Morphine is underutilized, resulting in unnecessary suffering of dying patients Unit 11 Part 1: Palliative care, Pain Management Slide 17

18. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Morphine Use in Namibia Simplest formulation: MIST morphine 15 mg/10 ml solution N$1 per liter Schedule 1 Pharmacists or PMOs need to mix this Pharmacists’ assistants cannot legally mix it (morphine powder schedule 7) Once mixed, pharmacists’ assistants may dispense Most potent formulation 100 mg/5 ml solution Schedule 7 Most restricted Under control of PMO / Medical Superintendent / Pharmacist Unit 11 Part 1: Palliative care, Pain Management Slide 18

19. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Morphine Use in Namibia (2) Use the schedule 1 solution 15 mg/10 ml No maximum dose of MS, titrate to effect and tolerance Always prescribe a laxative Bisacodyl is effective Extremely effective but underused in Namibia More advocacy is needed to promote morphine use as part of palliative care Unit 11 Part 1: Palliative care, Pain Management Slide 19

20. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Adjuvant Pain Medications Neuropathic Pain DrugDosage Amitriptyline10-25 mg at bedtime Other anti-depressants (SSRI)*Standard doses Carbamazapine200 mg tds Gabapentine*300 – 800 mg tds *not included in the Namibian Guidelines Unit 11 Part 1: Palliative care, Pain Management Slide 20

21. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Adjuvant Pain Medications Intestinal Colic DrugDosage Atropine 0.02mg Hyoscyamine 0.1mg Phenobarbitol 16.2mg Scopolamine 6.5mg 1 – 2 tabs 3-4 x daily Dicyclomine20 mg 4 x day Hyoscyamine0.125-0.25 mg q4h prn Propantheline15 mg 4 x day Unit 11 Part 1: Palliative care, Pain Management Slide 21

22. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Adjuvant Pain Medications Bone and Inflammatory pain DrugDosage Non-steroidal anti-inflammatory drugs (NSAIDs) Ibuprofen200-400 mg tds Indomethacin25 mg tds Unit 11 Part 1: Palliative care, Pain Management Slide 22

23. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Adjuvant Pain Medications Opioid Toxicity DrugDosage Nausea Haloperidol Promethazine 1.5 mg bedtime 10 mg bedtime Constipation Stool softeners (Colace) Laxatives (Sennekot, Mg Citrate) Unit 11 Part 1: Palliative care, Pain Management Slide 23

24. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Adjuvant Pain Medications Anti-Anxiety Medications DrugDosage Lorazepam Hydroxyzine Haloperidol 1 mg bedtime 25 mg tds 1.5 mg bedtime Anti-pruritics Hydroxyzine Promethazine 25 mg tds 10 mg bedtime Unit 11 Part 1: Palliative care, Pain Management Slide 24

25. Training on Clinical Care of HIV, AIDS and Opportunistic Infections Key Points 1.Relief of pain and other symptoms is part of care throughout the course of HIV disease 2.Specific treatment of illnesses and symptom relief improve the quality of life 3.In persons near the end of life, relief of symptoms is the main focus of care Unit 11 Part 1: Palliative care, Pain Management Slide 25