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Pain Management In Palliative Care. Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, WRHA Palliative Care Medical Director, Pediatric Symptom Management Service. Pain.

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pain management in palliative care
Pain Management In Palliative Care

Mike Harlos MD, CCFP, FCFP

Professor and Section Head, Palliative Medicine, University of Manitoba

Medical Director, WRHA Palliative Care

Medical Director, Pediatric Symptom Management Service

slide2
Pain

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

clinical terms for the sensory disturbances associated with pain
Clinical Terms For The Sensory Disturbances Associated With Pain
  • Dysesthesia – An unpleasant abnormal sensation, whether spontaneous or evoked.
  • Allodynia – Pain due to a stimulus which does not normally provoke pain, such as pain caused by light touch to the skin
  • Hyperalgesia – An increased response to a stimulus which is normally painful
  • Hyperesthesia - Increased sensitivity to stimulation, excluding the special senses. Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms should be used wherever they are applicable.
approach to pain control in palliative care
Approach To Pain Control in Palliative Care
  • Thorough assessment by skilled and knowledgeable clinician
    • History
    • Physical Examination
  • Pause here - discuss with patient/family the goals of care, hopes, expectations, anticipated course of illness. This will influence consideration of investigations and interventions
  • Investigations – X-Ray, CT, MRI, etc - if they will affect approach to care
  • Treatments – pharmacological and non-pharmacological; interventional analgesia (e.g.. Spinal)
  • Ongoing reassessment and review of options, goals, expectations, etc.
types of pain

Visceral

Somatic

  • bones, joints
  • connective tissues
  • muscles
  • Organs – heart, liver, pancreas, gut, etc.

Deafferentation

Sympathetic Maintained

Peripheral

TYPES OF PAIN

NEUROPATHIC

NOCICEPTIVE

slide6

Somatic Pain

  • Aching, often constant
  • May be dull or sharp
  • Often worse with movement
  • Well localized
  • Eg/
  • Bone & soft tissue
  • chest wall
slide7

Visceral Pain

  • Constant or crampy
  • Aching
  • Poorly localized
  • Referred
  • Eg/
  • CA pancreas
  • Liver capsule distension
  • Bowel obstruction
slide10
“Describing pain only in terms of its intensity is like describing music only in terms of its loudness”

von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162

pain history
PAIN HISTORY
  • Description: severity, quality, location, temporal features, frequency, aggravating & alleviating factors
  • Previous history
  • Context: social, cultural, emotional, spiritual factors
  • Meaning
  • Interventions: what has been tried?
slide13

Medication(s) Taken

  • Dose
  • Route
  • Frequency
  • Duration
  • Efficacy
  • Adverse effects
physical exam in pain assessment inspection observation
Physical Exam In Pain AssessmentInspection / Observation

“You can observe a lot just by watching” Yogi Berra

  • Overall impression… the “gestalt”?
  • Facial expression: Grimacing; furrowed brow; appears anxious; flat affect
  • Body position and spontaneous movement: there may be positioning to protect painful areas, limited movement due to pain
  • Diaphoresis – can be caused by pain
  • Areas of redness, swelling
  • Atrophied muscles
  • Gait
  • Myoclonus – possibly indicating opioid-induced neurotoxicity
physical exam in pain assessment palpation
Physical Exam In Pain AssessmentPalpation
  • Localized tenderness to pressure or percussion
  • Fullness / mass
  • Induration / warmth
physical exam in pain assessment neurological examination
Physical Exam In Pain AssessmentNeurological Examination
  • Important in evaluating pain, due to the possibility of spinal cord compression, and nerve root or peripheral nerve lesions
  • Sensory examination
    • Areas of numbness / decreased sensation
    • Areas of increased sensitivity, such as allodynia or hyperalgesia
  • Motor (strength) exam - caution if bony metastases (may fracture)
  • Deep tendon reflexes – intensity, symmetry
    • Hyperreflexia and clonus: possible upper motor neuron lesion, such as spinal cord compression or cerebral metastases.
    • Hyoporeflexia - possible lower motor neuron impairment, including lesions of the cauda equina of the spinal cord or leptomeningeal metastases.
  • Sacral reflexes – diminished rectal tone and absent anal reflexes may indicate cauda equina involvement of by tumour
physical exam in pain assessment other exam considerations
Physical Exam In Pain AssessmentOther Exam Considerations

Further areas of focus of the physical examination are determined by the clinical presentation.

Eg: evaluation of pleuritic chest pain would involve a detailed respiratory and chest wall examination.

non pharmacological pain management
Non-Pharmacological Pain Management
  • Acupuncture
  • Cognitive/behavioral therapy
  • Meditation/relaxation
  • Guided imagery
  • TENS
  • Therapeutic massage
  • Others…
slide20

3

By the

2

Clock

1

W.H.O. ANALGESIC LADDER

Strong opioid

+/- adjuvant

Weak opioid

+/- adjuvant

Pain persists or increases

Non-opioid

+/- adjuvant

slide21

STRONG OPIOIDS

  • most commonly use:
    • morphine
    • Hydromorphone (Dilaudid ®)
    • transdermal fentanyl (Duragesic®)
    • oxycodone
    • Methadone
  • DO NOT use meperidine (Demerolâ) long-term
    • active metabolite normeperidine®seizures
slide22

OPIOIDS and

INCOMPLETE CROSS-TOLERANCE

  • conversion tables assume that tolerance to a specific opioid is fully “crossed over” to other opioids.
  • cross-tolerance unpredictable, especially in:
    • high doses
    • long-term use
  • divide calculated dose in ½ and titrate
slide23

TITRATING OPIOIDS

  • dose increase depends on the situation
  • dose ­ by 25 - 100%

EXAMPLE: (doses in mg q4h)

slide27

TOLERANCE

PSYCHOLOGICAL

DEPENDENCE /

ADDICTION

PHYSICAL

DEPENDENCE

slide28

TOLERANCE

A normal physiological phenomenon in which increasing doses are required to produce the same effect

Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

slide29

PHYSICAL DEPENDENCE

A normal physiological phenomenon in which awithdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered

Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

slide30

PSYCHOLOGICAL DEPENDENCE

and ADDICTION

A pattern of drug use characterized by a continued craving for an opioid which is manifest as compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drug

Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

slide31

Changing Route Of Administration

In Chronic Opioid Dosing

  • po / sublingual / rectal routes
  • SQ / IV / IM routes

reduce by ½

slide32

Using Opioids for Breakthrough Pain

  • Patient must feel in control, empowered
  • Use aggressive dose and interval
  • Patient Taking Short-Acting Opioids:
    • 50 - 100% of the q4h dose, given q1h prn
  • Patient Taking Long-Acting Opioids:
    • 10 - 20% of total daily dose given, q1h prn
    • with short-acting opioid preparation
opioid side effects
Opioid Side Effects
  • Constipation – need proactive laxative use
  • Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol)
  • Urinary retention
  • Itch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great success
  • Dry mouth
  • Respiratory depression – uncommon when titrated in response to symptom
  • Drug interactions
  • Neurotoxicity (OIN):delirium, myoclonus ® seizures
slide35

Delirium

Hyperalgesia

OpioidsIncreased

Agitation

OpioidsIncreased

Misinterpretedas Disease-Related Pain

Misinterpretedas Pain

Spectrum of Opioid-Induced Neurotoxicity

Opioidtolerance

Mild myoclonus(eg. with sleeping)

Seizures,Death

Severe myoclonus

oin treatment
OIN: Treatment
  • Switch opioid (rotation) or reduce opioid dose; usually much lower than expected doses of alternate opioid required… often use prn initially
  • Hydration
  • Benzodiazepines for neuromuscular excitation
adjuvant analgesics
Adjuvant Analgesics
  • first developed for non-analgesic indications
  • subsequently found to have analgesic activity in specific pain scenarios
  • Common uses:
    • pain poorly-responsive to opioids (eg. neuropathic pain), or
    • with intentions of lowering the total opioid dose and thereby mitigate opioid side effects.
adjuvants used in palliative care
Adjuvants Used In Palliative Care
  • General / Non-specific
    • corticosteroids
    • cannabinoids (not yet commonly used for pain)
  • Neuropathic Pain
    • gabapentin
    • antidepressants
    • ketamine
    • topiramate
    • clonidine
  • Bone Pain
    • bisphosphonates
    • (calcitonin)
slide39

CORTICOSTEROIDS AS ADJUVANTS

  • ¯ inflammation
  • ¯ edema
  • ¯ spontaneous nerve depolarization

}

¯ tumor mass effects

slide41

DEXAMETHASONE

  • minimal mineralcorticoid effects
  • po/iv/sq/?sublingual routes
  • perhaps can be given once/day; often given more frequently
  • If an acute course is discontinued within 2 wks, adrenal suppression not likely
treatment of neuropathic pain
Treatment of Neuropathic Pain

Pharmacologic treatment

  • Opioids
  • Steroids
  • Anticonvulsants – gabapentin, topiramate
  • TCAs (for dysesthetic pain, esp. if depression)
  • NMDA receptor antagonists: ketamine, methadone
  • Anesthetics

Radiation therapy

Interventional treatment

  • Spinal analgesia
  • Nerve blocks
gabapentin
Gabapentin
  • Common Starting Regimen
    • 300 mg hs Day 1, 300 mg bid Day2, 300 mg tid Day 3, then gradually titrate to effect up to 1200 mg tid
  • Frail patients
    • 100 mg hs Day 1, 100 mg bid Day 2, 100 mg tid Day 3, then gradually titrate to effect
slide44

Incident Pain

Pain occurring as a direct and immediate consequence of a movement or activity

slide45

Circumstances In Which

Incident Pain Often Occurs

  • Bone metastases
  • Neuropathic pain
  • Intra-abd. disease aggravated by respiration
    • “incident” = breathing
    • ruptured viscus, peritonitis, liver hemorrhage
  • Skin ulcer: dressing change, debridement
  • Disimpaction
  • Catheterization
slide46

Incident

Incident

Incident

Having a steady level of enough opioid to treat the peaks of incident pain...

...would result in excessive dosing for the periods between incidents

Pain

Time

slide47

Fentanyl and Sufentanil

  • synthetic µ agonist opioids
  • highly lipid soluble
    • transmucosal absorption; effect in approx 10 min
    • rapid redistribution, including in / out of CSF; lasts approx 1 hr.
  • fentanyl » 100x stronger than morphine
  • sufentanil » 1000x stronger than morphine

10 mg morphine

» 10 µg sufentanil

» 100 µg fentanyl

slide48

INCIDENT PAIN PROTOCOL

(see also http://palliative.info)

slide49

INCIDENT PAIN PROTOCOL ctd...

  • fentanyl or sufentanil is administered SL 10 min. prior to anticipated activity
  • repeat q 10min x 2 additional doses if needed
  • increase to next step if 3 total doses not effective
  • physician order required to increase to next step if within an hour of last dose
  • the Incident Pain Protocol may be used up to q 1h prn
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