PALLIATIVE CARE: WHO Definition The active total care of patients whose disease is not responsive to curative treatment....

SUFFERING EMOTIONAL PSYCHOSOCIAL PHYSICAL SPIRITUAL

1. Adequate knowledge base 2. Attitude / Behaviour / Philosophy Active, aggressive management of suffering Active, aggressive management of suffering Team approach Team approach Recognizing death as a natural closure of life Recognizing death as a natural closure of life Broadening your concept of successful care Broadening your concept of successful care Effective nursing / medical care of the dying involves:

Cure/Life-prolongingIntent Palliative/ Comfort Intent Bereavement DEATHDEATH Active Treatment PalliativeCare DEATHDEATH EVOLVING MODEL OF PALLIATIVE CARE

SYMPTOMS IN ADVANCED CANCER Ref: Bruera 1992 Why Do We Care? Conference; Memorial Sloan-Kettering

PREVALENCE OF CANCER PAIN From Portenoy; Cancer 63:2298, 1989

TYPES OF PAIN NEUROPATHIC NOCICEPTIVE Somatic Visceral Deafferentation Sympathetic Maintained Peripheral

SomaticVisceral Features Constant Aching Well localized Constant or crampy Aching Poorly localized Referred Examples Bone metastases Pancreatic CA Liver tumor Bowel obstruction NOCICEPTIVE PAIN

COMPONENTDESCRIPTORSMEDICATIONS Steady Burning, Tingling Constant, Aching Squeezing, Itching Allodynia Hypersthesia Gabapentin Tricyclic antidepressants Corticosteroids Mexilitene Paroxysmal Stabbing Shocklike, electric Shooting Gabapentin Baclofen Tegretol Corticosteroids Mexilitene FEATURES OF NEUROPATHIC PAIN

PAIN HISTORY Temporal FeaturesTemporal Features Daily FrequencyDaily Frequency LocationLocation SeveritySeverity QualityQuality Aggravating & Alleviating FactorsAggravating & Alleviating Factors Previous HistoryPrevious History MeaningMeaning

+/- adjuvant Non-opioid Weak opioid Strong opioid Pain persists or increases By the Clock W.H.O. ANALGESIC LADDER +/- adjuvant 1 2 3

STRONG OPIOIDS most commonly use: most commonly use: – morphine – hydromorphone – transdermal fentanyl (Duragesic®) – Methadone DO NOT use meperidine (Demerol ) long-term DO NOT use meperidine (Demerol ) long-term – active metabolite normeperidine seizures

OPIOIDS and INCOMPLETE CROSS-TOLERANCE conversion tables assume full cross-tolerance conversion tables assume full cross-tolerance cross-tolerance unpredictable, especially in: cross-tolerance unpredictable, especially in: – high doses – long-term use divide calculated dose in ½ and titrate divide calculated dose in ½ and titrate

CONVERTING OPIOIDS MedicationApprox. Equiv. Oral Dose (mg) Morphine10 Hydromorphone2 Methadone1 Codeine60 NB: Does not consider incomplete cross-tolerance

TITRATING OPIOIDS dose increase depends on the situation dose increase depends on the situation dose by % dose by % EXAMPLE: (doses in mg q4h)

Using Opioids for Breakthrough Pain Patient must feel in control, empowered Use aggressive dose and interval Patient Taking Short-Acting Opioids: % of the q4h dose given q1h prn Patient Taking Long-Acting Opioids: % of total daily dose given q1h prn with short-acting opioid preparation

TOLERANCE PHYSICALDEPENDENCE PSYCHOLOGICAL DEPENDENCE / ADDICTION

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

PHYSICAL DEPENDENCE A normal physiological phenomenon in which a withdrawal 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

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

In chronic opioid dosing: po / sublingual / rectal routes po / sublingual / rectal routes sq / iv / IM routes reduce by ½

ADJUVANT DRUGS primary indication usually other than pain primary indication usually other than pain analgesic in some painful conditions analgesic in some painful conditions enhance analgesia of opioids enhance analgesia of opioids other roles: other roles: – treat opioid side effects – treat symptoms associated with pain

ANTI- CHOLINERGIC EFFECTS AmitriptylineNortriptylineDesipramine

inflammation inflammation edema edema spontaneous nerve depolarization spontaneous nerve depolarization tumor mass effects tumor mass effects CORTICOSTEROIDS AS ADJUVANTS }

IMMEDIATELONG-TERM Psychiatric Hyperglycemia risk of GI bleed gastritis aggravation of existing lesion (ulcer, tumor) Immunosuppression Proximal myopathy ** often < 15 days ** Cushings syndrome Osteoporosis Aseptic / avascular necrosis of bone CORTICOSTEROIDS: ADVERSE EFFECTS

DEXAMETHASONE: DOSING minimal mineralcorticoid effects – po/iv/sq/?sublingual routes can be given once/day; often given bid – qid to facilitate titration typically administer as follows: » 4 mg qid x 7 days then » 4 mg tid x 1 day then » 4 mg bid x 1 day then » 4 mg once/day x 1 day then D/C