Pain management in palliative care 3

Pain management in palliative care 3
Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

Outline Review of days 1 & 2 Treatment in children
Non-pharmacological treatment Treatment in HIV/AIDS Special situations MKF 2016

Overview of palliative care
Total Care Continuum of Care

Presentation/Diagnosis
Traditional Model of Care Curative Care Hospice Presentation/Diagnosis Death MKF 2016 4

Palliative Care in the Continuum
Diagnosis Death HEALTH ILLNESS DEATH Curative & Life Prolonging Care Palliative Care Symptom Management Life Closure EOL/ Dying Prevention Bereavement CURATIVE CARE HOSPICE CARE MKF 2016

Dame Cicely Saunders Concept of Total Pain
Physical Spiritual Psychological Social Total Pain Dame Cicely Saunders Concept of Total Pain MKF 2016

Overview of pain management
ECG of pain Mechanism of pain Types of pain WHO analgesic ladder

Pain Assessment . . . Symptom Assessment – PQRST strategy
What Provokes or Palliates the pain? What is the Quality of the pain? What Regions are involved, and does it Radiate? What is the Severity of the pain (0 – 10 scale)? What is the Timing of the pain? Detailed pain medication and treatment history Prior opioid (prescription or not) and substance use MKF 2016

Pain Terminology Pain Type Features Examples Nociceptive (somatic)
Sharp, aching, stabbing pain Localized, acute or chronic Musculoskeletal injury Bone pain (fractures, mets) Neuropathic Burning, shooting, ‘electric’ pain Radiates, often chronic Diabetic neuropathy Post-herpetic neuralgia Visceral Gnawing, crescendo pain Poorly localized Bowel obstruction Angina MKF 2016

WHO Analgesic Ladder: adults
Step 3 Strong opioid Step 2 Weak opioid Step up if pain persists or increases Severe pain Step up if pain persists or increases Step 1 Non-opioid Moderate pain +/- non-opioid +/- adjuvant Mild pain +/- non-opioid +/- adjuvant +/- adjuvant Consider prophylactic laxatives to avoid constipation Non-opioids ibuprofen or other NSAID, paracetamol (acetaminophen), or aspirin Weak opioids codeine, tramadol, or low-dose morphine Strong opioids morphine, fentanyl, oxycodone, hydromorphone, buprenorphine Adjuvants antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid Combining an opioid and non-opioid is effective, but do not combine drugs of the same class. Time doses based on drug half-life (“dose by the clock”); do not wait for pain to recur 10 Adapted by Treat the Pain from World Health Organization (accessed 7 November 2013)

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Breakthrough, emergency, and incident pain

Breakthrough pain Breakthrough pain: a sudden, temporary flare of severe pain that occurs on a background of otherwise controlled pain May be more common during first three days of treatment as morphine dose is titrated from starting dose to effective dose MKF 2016

Diagnostic criteria Stable analgesic regimen in the previous 48 hours
Presence of controlled background pain in the previous 24 hours (i.e. average pain score <5 out of 10) Temporary flare of severe or excruciating pain in the previous 24 hours MKF 2016

Rescue dose Rescue dose: a dose of immediate-release morphine that is the same as the dose given every 4 hours and can be given as often as required to treat breakthrough pain Note these in the patient chart Write orders that include rescue doses MKF 2016

Pain emergency The goal is to control pain (i.e. to get pain score below 5 out of 10) If patient is in excruciating pain (pain score=9 or 10), it is considered a pain emergency Administer rescue dose intravenously (IV) Remember to convert oral dose to IV dose by dividing by 2- 3 Otherwise rescue doses can be oral Wait for dose to take effect (10 minutes for IV and 30 minutes for oral) and then reassess Repeat dose if pain score is 5 or higher MKF 2016

Incident pain and end-of-dose failure
Types of pain that are similar to breakthrough pain Incident pain End-of-dose failure MKF 2016

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Side effects and toxicity of analgesics

Side effects Step 1 drugs: Acetaminophen NSAIDS Step 2 drugs:
Codeine, etc Step 3 drugs MKF 2016

Step 3 analgesic: morphine
When used correctly, problems like dependency, addiction, tolerance, and respiratory depression are rare Opioids are not toxic to any organ No contraindications except history of allergic reactions (rare) MKF 2016

Constipation is a very common side effect of all opioids and does not resolve spontaneously Laxatives should be prescribed as prophylaxis unless patient has diarrhoea Treat with a stimulant laxative i.e. Bisacodyl 5mg at night, increasing to 15mg if needed MKF 2016

Nausea and vomiting Usually mild and resolves within one week Anti-emetics (metoclopramide or haloperidol) can be given for the first few days of treatment Metoclopromide 10mg every 8 hours or haloperidol 1.5mg once a day Itching Less common Treat with chlorpheniramine MKF 2016

Opioid toxicity Toxic effects of opioids are rare when they are used in appropriate doses Signs include Drowsiness that does not improve Confusion Hallucinations Myoclonus (abrupt spasms or muscle twitching) Respiratory depression (slow breathing) Pinpoint pupils MKF 2016

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Addiction and dependence
Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions.

Risk of addiction in medical use of opioids
According to the World Health Organization: A systematic review of research papers concludes that only 0.43% of patients with no previous history of substance abuse treated with opioid analgesics to relieve pain abused their medication and only 0.05% developed dependence syndrome Fishbain et al (2008): Among chronic pain patients with no history of opioid abuse/addiction, incidence of abuse/addiction is 0.19% MKF 2016

MKF 2016

Treatment in children Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

Objectives Review methods of assessing pain in children
Discuss treatment options and dosing for children based on the age of the child and their level of pain

Three ways to assess pain in children
Ask the child: FACES scale Ask the parent or caregiver Ask about previous exposure to pain, verbal pain indicators, usual behavior or temperament Observe the child: FLACC scale The child is the best person to report their pain Children’s Palliative Care in Africa, 2009

Wong-Baker FACES scale
Use in children who can talk (usually 3 years and older) Explain to the child that each face is for a person who feels happy because he has no pain, or a little sad because he has a little pain, or very sad because he has a lot of pain Ask the child to pick one face that best describes his or her current pain intensity Record the number of the pain level that the child reports to make treatment decisions, follow-up, and compare between examinations Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for Palliative Care (2007)

FLACC scale Use in children less than 3 years of age or older children who can’t talk Use it like an APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score, arriving at a score out of 10 ICPCN (2009): Adapted from Merkel et al

Practice using FLACC scale
Samuel is 18 months old. You observe that he is withdrawn, kicking his legs, and squirming. His is constantly crying or screaming, but is calmed down by breastfeeding. Category Score Face Legs Activity Cry Consolability Total Score 1 2 Score 1 2 Score 1 2 7 Score 1 2 Score 1 Score 1 2

WHO Analgesic Ladder: Pediatric
Step 2 Strong opioid Step up if pain persists or increases Moderate or Severe pain Step 1 Non-opioid Mild pain +/- non-opioid +/- adjuvant +/- adjuvant Consider prophylactic laxatives to avoid constipation Non-opioids Age>3 mos: ibuprofen or paracetamol (acetaminophen); Age<3 mos: paracetamol Strong opioids morphine (medicine of choice) or fentanyl, oxycodone, hydromorphone, buprenorphine Adjuvants antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid Combining an opioid and non-opioid is effective, but do not combine drugs of the same class. Time doses based on drug half-life (“dose by the clock”); do not wait for pain to recur 36 Ref: Adapted by Treat the Pain from World Health Organization (accessed 7 November 2013)

WHO ladder: pediatric Recently updated guidelines from the World Health Organization (WHO) recommend using a 2-step ladder which does not include the rung for weak opioids Weak opioids are not recommended for use in children Codeine Safety and efficacy problems related to genetic variability that affects metabolism Low analgesic effect in infants and young children Tramadol Data are lacking on safety and efficacy in children WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Step 1: mild pain Paracetamol and ibuprofen are the only medicines in this step No other NSAIDs are recommended Infants <3 months old Only paracetamol is recommended Children >3 months old Paracetamol or ibuprofen can be used WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Dosing of Step 1 analgesics
Medicine <1 month 1-3 months 3 months-12 years Maximum daily dose Paracetamol 5-10mg/kg every 6-8 hours 10mg/kg every 4-6 hours 10-15mg/kg every 4-6 hours (max 1g at a time) 4 doses per day Ibuprofen Not recommended 40mg/kg/day * Children with poor nutritional state may be more susceptible to toxicity at standard doses WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Step 2: moderate or severe pain
“There is no other class of medicines than strong opioids that is effective in the treatment of moderate and severe pain. Therefore, strong opioids are an essential element in pain management.” World Health Organization WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Step 2: moderate or severe pain
Morphine is the “medicine of choice” Alternatives can be used if a child experiences intolerable side-effects As with adults, there is no maximum dose for opioids Titrate upward to find the dose that relieves pain with tolerable side-effects Constipation is a common side effect, and all children taking opioids should also take a stimulant laxative and a stool softener WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Starting dose for opioid-naïve neonates
Medicine Route Starting dose Morphine IV/Sc injection 25-50mcg/kg every 6 hours IV infusion Initial IV dose 25-50mcg/kg, then 5-10mcg/kg/hour 100mcg/kg every 4 or 6 hours Fentanyl IV injection 1-2mcg/kg every 2 to 4 hours Initial IV dose 1-2mcg/kg, then 0.5-1mcg/kg/hour Administer IV morphine slowly over at least 5 minutes IV doses are based on acute pain management and sedation. Lower doses are required for non-ventilated neonates Administer IV fentanyl slowly over 3-5 minutes WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Starting dose for opioid-naïve infants (1 mo-1 yr)
Medicine Route Starting dose Morphine Oral (immediate release) 80-200mcg/kg every 4 hours IV/Sc injection 1-6 months: 100mcg/kg every 6 hours 6-12 months: 100mcg/kg every 4 hours (max 2.5mg/dose) IV infusion 1-6 months: Initial IV dose: 50mcg/kg, then: 10-30mcg/kg/hour 6-12 months: Initial IV dose: mcg/kg then: 20-30mcg/kg/hour Sc infusion 1-3 months: 10mcg/kg/hour 3-12 months: 20mcg/kg/hour Administer IV morphine slowly over at least 5 minutes WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Starting dose for opioid-naïve infants (1 mo-1 yr)
Medicine Route Starting dose Fentanyl IV injection 1-2mcg/kg every 2 to 4 hours IV infusion Initial IV dose 1-2mcg/kg, then 0.5-1mcg/kg/hour Oxycodone Oral (immediate release) 50-125mcg/kg every 4 hours IV doses of fentanyl are based on acute pain management and sedation dosing information WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Starting doses for opioid-naïve children (1-12 yrs)
Medicine Route Starting dose Morphine Oral (immediate release) 1-2 years: mcg/kg every 4 hours 2-12 years: mcg/kg every 4 hours (max 5mg) Oral (prolonged release) mcg/kg every 12 hours IV/Sc injection 1-2 years: 100mcg/kg every 4 hours 2-12 years: mcg/kg every 4 hours (max 2.5mg) IV infusion Initial IV dose: mcg/kg, then mcg/kg/hour Sc infusion 20mcg/kg/hour Administer IV morphine slowly over at least 5 minutes WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Starting doses for opioid-naïve children (1-12 yrs)
These opioids are more complex and should be started by an experienced provider Medicine Route Starting dose Fentanyl IV injection 1-2mcg/kg, repeated every minutes IV infusion Initial IV dose 1-2mcg/kg, then 1mcg/kg/hour Hydromorphone Oral (immediate release) 30-80mcg/kg/hour every 3 to 4 hours (max 2mg/dose) IV/Sc injection 15mcg/kg every 3 to 6 hours Methadone mcg/kg every 4 hours for the first 2-3 doses, then every 6 to 12 hours (max 5mg/dose initially) Oxycodone mcg/kg every 4 hours (max 5mg/dose) Oral (slow release) 5mg every 12 hours Administer IV fentanyl slowly over 3-5 minutes Hydromorphone is a potent opioid and significant differences exist between oral and intravenous dosing. Use extreme caution when converting from one route to another. In converting from parenteral to oral hydromorphone, doses may need to be titrated up to 5 times the IV dose. Administer IV hydromorphone slowly over 2-3 minutes Due to the complex nature and wide inter-individual variation in pharmacokinetics, methadone should only be commenced by experienced practitioners WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

General principles Dose at regular intervals
Medicines should always be given on a regular schedule and not “as needed”, except for rescue doses Use the appropriate route of administration Medicines should be given by the simplest, most effective, and least painful route Oral is preferred IV or subcutaneous, rectal, or transdermal are alternatives when oral is not feasible IM is discouraged because it is painful Adapt treatment to the individual child Titrate to get to the correct dose WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

Side effects of opioids
Opioids are generally well-tolerated Mild sedation for first 48 hours is normal while child catches up on sleep Constipation: treat with laxatives Pruritis: treat with topical treatments (calamine or hydrocortizone) or oral antihistamines Urinary retention: treat with carbachol or bethanechol; catheterization may be required Children’s Palliative Care in Africa, Amery (2009)

Co-analgesia in children
The WHO does not recommend corticosteroids or biphosphonates to treat pain in children Neuropathic pain in children Consult an expert WHO guidance in this area is limited due to lack of evidence WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. WHO (2012)

Procedural pain management principles
Avoid non-necessary procedures Prepare for the procedure Involve the child and family Encourage the parents to be helpful and supportive Carry out procedures in child-friendly area away from the bed Use non-pharmacological and pharmacological interventions to manage pain and anxiety After completing the procedure, congratulate the child and instill a sense of achievement Children’s Palliative Care in Africa, Amery (2009)

Procedural pain management
Drugs to use Topical anaesthetic agents (EMLA cream) Local anaesthetic: S/c lidocaine (make sure it is at body temperature and buffer with sodium bicarbonate to reduce pain of administration) If anxiety, rather than pain, is the issue: sedate with benzodiazepine, pedichloryal (50-100mg/kg by mouth) or promethizine (5mg/kg by mouth) If pain is the issue: use opioids in treatment doses Children’s Palliative Care in Africa, Amery (2009)

Take home messages Pain in children can be assessed using observation and easy tools Children as young as 3 years old can indicate their severity of the pain For children, the WHO analgesic ladder is 2 steps

Non-pharmacological treatment

Objectives Discuss various forms of non-pharmacological methods for addressing pain Review how and when the various methods can complement pharmacological options

Pain is influenced by psychological, cultural, social, and spiritual factors which should also be addressed Non-pharmacological treatments do not replace pharmacological treatment, but they may be complementary Reduce symptoms Affect pain perception Assist with relaxation Improve sleep TOTAL PAIN PHYSICAL PSYCHOLOGICAL EMOTIONAL SPIRITUAL Beating Pain, 2nd Ed. APCA (2012)

Symptoms may be reduced with use of: Surgery: Can address the source of pain Radiotherapy: Treat local pain due to tumor infiltration Beating Pain, 2nd Ed. APCA (2012)

Other non-pharmacological treatments may reduce the perception of pain, assist in relaxation, or improve sleep Dance therapy: Uses movement to improve mental and physical well-being Music therapy: Listening to or making music may lower stress and improve mood Acupuncture: Insertion and manipulation of needles, pressure, or low-frequency electric current at specific points Beating Pain, 2nd Ed. APCA (2012)

Physical therapy: Movement helps to build strength, maintain energy, and contributes to overall well-being Positioning therapy: Moving bedridden patients and changing their position prevents bed sores and injury Massage therapy: Rubbing and manipulating muscles, which increases circulation and relaxation Beating Pain, 2nd Ed. APCA (2012)

Social support: Supportive counseling and referrals to community resources and services can assist patients with finding needed emotional support Spiritual and religious support: Depending on their beliefs and faith, some patients may find support through prayer and meditation Herbs: May be helpful or harmful Hot and cold therapy: Either one may help to decrease pain Beating Pain, 2nd Ed. APCA (2012)

Relaxation: Most commonly used non-pharmacological technique-teach patients to intentionally relax to reduce tension and stress Deep and slow breathing: Influences autonomic and pain processing in combination with relaxation Distraction: Focus the patient’s attention away from the pain Reflexology: Use pressure points in the hand and feet that correspond to other parts of the body Aromatherapy: Use essential oils to balance, relax, and stimulate the body, mind, and soul Beating Pain, 2nd Ed. APCA (2012)

Remember Not all of these approaches will work for everyone
Non-pharmacological treatments complement pharmacological treatment-they should not be used as a substitute for pharmacological treatment Do not assume that all non-pharmacological treatments are safe. Some have contraindications Just because natural remedies, such as herbs, have been around for a long time does not mean that they work or that they are harmless Beating Pain, 2nd Ed. APCA (2012)

Take home messages Non-pharmacological methods may help in pain management Non-pharmacological methods may have contraindications Non-pharmacological methods should complement, not replace, pharmacological treatments

Treatment in HIV/AIDS Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions.

Objectives Discuss common sources of pain for patients with HIV/AIDS
Review the clinical presentation, causes, and treatment for specific HIV/AIDS-related pain

Pain in HIV/AIDS Pain in HIV is common, has various presentations, and can result from multiple sources at the same time Pain may be related to HIV infection, immunosuppression, or HIV therapy Many people with HIV/AIDS also have cancer Beating Pain, 2nd Ed. APCA (2012)

Common sources of pain in HIV/AIDS
Cutaneous/Oral Visceral Somatic Neurological/Headache Kaposi’s sarcoma Oral cavity pain Herpes zoster Oral/oesophageal candidiasis Tumours Gastritis Pancreatitis Infection Biliary tract disorders Rheumatological disease Back pain Myopathies HIV-related headaches: encephalitis, meningitis, etc. HIV-unrelated headaches: tension, migraine, etc. Iatrogenic (AZT) Peripheral neuropathy Herpes neuritis Neuropathies associated with DDI, D4T toxicities Alcohol, nutritional deficiencies Beating Pain, 2nd Ed. APCA (2012), adapted from Carr DB

Treatment of pain in HIV/AIDS
Follow the World Health Organization (WHO) analgesic ladder Use NSAIDs with caution in those with low platelets or those with a history of gastrointestinal disease such as peptic ulcer disease Adjuvants (co-analgesia) can be very useful Some antiretroviral medications interact with analgesics, so check interactions or consult with an expert Main interactions involve adjuvants: phenytoin, carbamazepine, dexamethasone, and amitriptyline Beating Pain, 2nd Ed. APCA (2012)

Peripheral neuropathy
Clinical presentation Causes Treatment Burning pain: hands and feet Pins and needles Allodynia (the experience of pain from a stimulus that would not usually cause pain in a normal individual) Pain relieved by local pressure HIV itself (distal sensory neuropathy) Post-herpetic neuralgia ARVs, especially D4T and Efavirenz Other treatments: chemotherapy, Isoniazid, Metronidazole Remove offending agents if possible: change from D4T to Abacavir or from Efavirenz to Ritonavir/Lopinavir Treat herpes zoster early with Acyclovir to limit post-herpetic neuralgia Use WHO analgesic ladder –NSAIDs and opioids Gabapentin in resistant cases Try topical analgesics For localized neuropathies-nerve block Beating Pain, 2nd Ed. APCA (2012)

Abdominal pain Clinical presentation Causes Treatment
Presents as acute or chronic pain TB abdomen MAC (mycobacterium avium complex) Pancreatitis Peptic ulcer disease Gastro-oesophageal reflux disease Gall bladder and biliary tract disease Malabsorption syndromes Drug side effects Neuropathic abdominal pain (diagnosis of exclusion) Diagnose and treat underlying cause if possible Start ARVs if indicated Treat pain according to WHO analgesic ladder Beware of ileus/constipation caused by opioids: can make pain worse Remember morphine causes contraction of sphincter of Oddi, so pethidine is a better choice in pancreatitis For MAC immune reconstitution inflammatory syndrome (IRIS), try low dose steroids Beware of NSAIDs and gastritis Beating Pain, 2nd Ed. APCA (2012)

Muscle spasm Clinical presentation Causes Treatment Muscle spasm
Caused by HIV itself in the form of HIV encephalopathy with increased tone Secondary to cerebral insults from bacterial or tuberculosis meningitis ARVs Levodopa (extrapyramidal dysfunction) Analgesics (Step 2: non-opioid + weak opioid) NSAIDs may help for musculoskeletal pain Baclofen (for muscle spasm, can cause seizures) Adjuvants, especially Rivotril Beating Pain, 2nd Ed. APCA (2012)

Raised intracranial pressure
Clinical presentation Causes Treatment Headache Focal neurological deficits Cryptococcal meningitis Toxoplasmosis Treat pain according to WHO analgesic ladder Morphine and pethidine are contraindicated for raised intracranial pressure Beating Pain, 2nd Ed. APCA (2012)

Take home message ARVs may not relieve all causes of pain for people people with HIV/AIDS and patients may need additional pain treatment Cancer is common in people living HIV/AIDS

Special situations Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

Objectives Discuss alternative options for assessing pain in patients that may have problems communicating PAINAD scale Review how to manage pain in elderly patients Determine how to assess and treat pain for patients with sickle cell disease

Pain in the elderly Chronic pain is common among the elderly
Dementia and problems communicating often make assessment of pain challenging Compliance with medications can also be a challenge Impaired vision Limited mobility Memory problems Beating Pain, 2nd Ed. APCA (2012)

Pain assessment Observational tools may be used to assess pain in patients who have trouble communicating their pain or are cognitively impaired Communication boards could also be used for this subset of patients Health care providers should assess the pain of such patients as accurately as possible Beating Pain, 2nd Ed. APCA (2012)

Options for cognitive impairment or dementia
Many patients who appear cognitively impaired may still be able to provide useful information concerning pain Interview caregivers: patterns of particular behaviors may have developed that indicate pain (e.g. placing a hand on the forehead for a headache) Review medical record for known pain-inducing pathology Observe facial expression, body posture, vocalizations, appetite, interactivity Utilize Pain Assessment in Advanced Dementia (PAINAD) Beating Pain, 2nd Ed. APCA (2012); Guide to Pain Management in Low-Resource Settings: International Association for the Study of Pain, 2010

Pain Assessment in Advanced Dementia (PAINAD) Scale
Items 1 2 Score Breathing independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation Noisy labored breathing. Long periods of hyperventilation. Cheyne-Stokes respiration Negative vocalization None Occasional moan or groan. Low level speech with a negative or disapproving quality Repeated troubled calling out. Loud moaning or groaning. Crying Facial expression Smiling or inexpressive Sad. Frightened. Frown Facial grimacing (an ugly or disapproving facial expression) Body language Relaxed Tense. Distressed pacing. Fidgeting Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out Consolability No need to console Distracted or reassured by voice or touch Unable to console, distract, or reassure Beating Pain, 2nd Ed. APCA (2012), adapted from Warden et al, 2003

Managing pain in the elderly
Include family in the process Provide written information and in clear writing, enlarged as needed Anticipate pain and treat accordingly Titrate doses individually Start low and titrate upward slowly Use care with adjuvant co-analgesia to avoid drug interactions and unwanted side effects Beating Pain, 2nd Ed. APCA (2012)

Pain in sickle cell disease
Most patients with sickle cell disease experience pain on a daily basis Crisis pain: the most severe pain experienced by sickle cell patients Patient feels that “all my bones are breaking” Reported to occur about 13% of all days Characterized by abrupt onset, episodic and unpredictable, and with severe pain May last several hours to a week or more Oxford Textbook of Palliative Medicine, (2010); Guide to Pain Management in Low-Resource Settings: International Association for the Study of Pain, 2010

Pain in sickle cell disease
Patients may need chronic pain management and rescue medication for acute pain crises Those with three or more pain crises per year are candidates for hydroxyurea therapy, which significantly decreases their occurrence Oxford Textbook of Palliative Medicine, (2010); Guide to Pain Management in Low-Resource Settings: International Association for the Study of Pain, 2010

Sickle cell pain treatment
Assess pain frequently and treat as an emergency Maintain adequate hydration Investigate other possible causes of pain, including complications of the diseases (acute chest syndrome, priapism, splenic sequestration, cholelithiasis) Do not withhold opioids when pain is severe: treat according to the WHO analgesic ladder Some patients may require chronic use of opioids on a daily basis to manage pain and improve function Oxford Textbook of Palliative Medicine, (2010); Guide to Pain Management in Low-Resource Settings: International Association for the Study of Pain, 2010

Alternative routes of administration
Use the oral route whenever possible Exceptions may be: Need for rapid pain relief in pain emergencies: intravenous or subcutaneous route Oral route is not accessible: rectal, buccal, intravenous, subcutaneous, nasogastric, or transdermal Check to see if dose conversion is needed to move from oral to alternative route Avoid intramuscular injection: causes more pain Beating Pain, 2nd Ed. APCA (2012).

Take home messages Though chronic pain is common in the elderly, pain can be assessed and managed, even for those suffering from dementia Sickle cell pain should be assessed frequently Sickle cell crisis should be treated as an emergency

Thank you Palliative Care Team
MKF 2016

Pain management in palliative care 3

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