Pain Management in Palliative Care

Pain Management in Palliative Care
Palliative Care Team MKF 2016

Outline Pre-test Introduction to palliative care Introduction to pain
Mechanism of pain Pain assessment WHO analgesic ladder Equianalgesic dosing MKF 2016

Introduction to palliative care
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 MKF 2016

MKF 2016

What is Palliative Care? WHO Definition
Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems physical, psychosocial and spiritual. MKF 2016

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

When does PC Start? MKF 2016

Presentation/Diagnosis
Traditional Model of Care Curative Care Hospice Presentation/Diagnosis Death MKF 2016 8

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

MKF 2016

Introduction to pain 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 By the end of the session, learners should be able to:
Define the term pain Name the common opioid analgesics Understand that the World Health Organization considers morphine to be an essential medicine Describe the disparity in access to morphine by country income level Give key advantages of morphine relative to other pain medicines Describe challenges that limit access to morphine Understand why pain treatment is important Name the simple treatment algorithm that relieves pain in 80-90% of people Challenge some common myths about pain treatment MKF 2016

Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Pain is a subjective experience. The experience varies from person to person and from time to time Pain is whatever the experiencing person says it is, existing wherever he says it does MKF 2016

Total pain: how patients experience pain
PHYSICAL PSYCHOLOGICAL EMOTIONAL SPIRITUAL Patients experience pain on several levels and effective treatment requires a holistic assessment This training program focuses on physical pain MKF 2016

Who suffers from pain? Pain is prevalent in almost all medical specialties including general practice, palliative care, oncology, internal medicine, haematology, and surgery Patients who are affected include people who have cancer, HIV, sickle-cell disease, those who have surgery or accidents, and potentially other patients Approximately 80% of people with advanced cancer and 50% of people with advanced HIV experience moderate or severe pain MKF 2016

Opioid analgesics for pain relief
Analgesics are medicines that relieve pain Opioids are medicines that are derived from opium poppy plants or synthetic formulations that act in the same way Weak opioids Codeine Tramadol Dihydrocodeine Strong opioids Morphine Fentanyl Oxycodone Hydrocodone Buprenorphine Methadone MKF 2016

World Health Organization
Opioid analgesics, including morphine, are considered essential medicines by the World Health Organization Strong opioid analgesics are the only treatment for moderate or severe pain recommended in World Health Organization guidelines No suitable alternatives have been found MKF 2016

Disparity in access to opioids
Opioids are on almost all national essential medicines lists, but access to them is severely limited in most low and middle- income countries, where 85% of the world’s population consumes just 7% of the medicinal opioids MKF 2016

Number of deaths with untreated pain (2012)
The lowest treatment coverage rates are: South Asia: 9% Sub-Saharan Africa: 20% MKF 2016

Access to morphine differs according to country income level
Maximum coverage rate for deaths in pain from HIV or cancer based on national consumption of opioid analgesics: High-income countries: 100% Middle-income countries: 62% Low-income countries: 19% People in lower income countries are significantly less likely to get pain treatment than people in higher-income countries MKF 2016

Opioid analgesics for pain relief
Opioids are the foundation of pain management for moderate or severe pain No organ toxicity, even at high doses and after prolonged use Side effects diminish over time Potential harmful side effects are avoidable when opioids are used correctly MKF 2016

Morphine advantages Most effective treatment for severe pain
Safe (if used according to guidelines) Effective Plentiful Inexpensive Easy-to-use MKF 2016

Challenges that limit access to morphine
Although morphine is inexpensive people lack access due to: Inadequate training or lack of knowledge of healthcare providers Cultural misperceptions about pain Lack of appropriate government policies or guidelines Legal and regulatory restrictions Weak procurement systems Disproportionate concern about diversion, addiction, and abuse Practices meant to prevent abuse of morphine that result in limited access for those in need of pain relief MKF 2016

Advantages of pain treatment
In low-resource countries, pain is the most common indication for visiting a health care practitioner Pain treatment: Improves compliance to curative treatment Extends survival for some patients Improves quality of life Improves patient – physician relationship Reduces unnecessary prolonged admission MKF 2016

MKF 2016

Mechanisms of pain 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 for this module
Discuss the ways pain can be characterised Duration Mechanism Origin Situation MKF 2016

Characterisations of pain
Pain can be described by its: Duration – acute or chronic Mechanism – nociceptive or neuropathic Origin – somatic or visceral Situation – incidental pain, breakthrough pain, procedural pain MKF 2016

Different mechanisms of pain
Why are they important? Pathophysiology is different Presentation is different Management is different MKF 2016

Duration: acute vs. chronic pain
Acute pain Presentation: characterized by help-seeking behavior such as crying and moving about in a very obvious manner Cause: definite injury or illness Signs/symptoms: Definite onset with limited and predictable duration Clinical signs of sympathetic over-activity: tachycardia, pallor, hypertension, sweating, grimacing, crying, anxious, pupillary dilation Example: trauma, surgery, or inflammation MKF 2016

Duration: acute vs. chronic pain
Presentation: Patients may not show signs of distress seen in acute pain Cause: chronic pathological process Under-treatment of acute pain can lead to changes in the central nervous system that result in chronic pain Signs/symptoms: Gradual or vague onset Continues and may become progressively more severe Patient may appear depressed and withdrawn Usually no signs of sympathetic over-activity MKF 2016

Mechanism: nociceptive pain
Nociceptive pain: caused when nerve receptors called nociceptors are irritated. Nociceptors exist both internally (visceral) and externally (somatic) Indicates that nerve pathways are intact MKF 2016

Nociceptive pain: somatic pain
Somatic pain: stimulation of nociceptors in the skin, soft tissues, muscle, or bone Pain usually is in a particular location Aching, throbbing, or persistent pain Causes: bone or soft tissue infiltration MKF 2016

Nociceptive pain: visceral pain
Visceral pain: stimulation of nociceptors in internal organs and hollow viscera organs Pain is often not in a single location Described as pressure, cramping, or squeezing pain Causes: blockage, swelling, stretching, or inflammation of the organs from any cause MKF 2016

Mechanism: neuropathic pain
Neuropathic pain: caused by damage to nerve pathways Described as burning, prickling, stinging, pins and needles, insects crawling under skin, numbness, hypersensitivity, shooting, or electric shock Causes: infiltration by cancer, HIV infection, or herpes zoster, drug-related peripheral neuropathy, central nervous system injury, or surgery MKF 2016

Situation Incident pain – occurs only in certain circumstances (e.g. after a particular movement) Breakthrough pain – a sudden, temporary flare of severe pain that occurs on a background of otherwise controlled pain Procedural pain – related to procedures or interventions MKF 2016

Assessment Jane has come to your clinic with pain she’s describing as constant shooting pain in her feet for the past four days. How would you classify her pain? A. Procedural pain B. Chronic, visceral pain C. Acute, neuropathic pain D. Acute, incident pain Answer C: MKF 2016

Take home message Knowing the differences in the mechanisms of pain is important to adequately and appropriately treat the pain MKF 2016

MKF 2016

Pain Assessment 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 Explain how pain scales are used to measure pain
Compare different scales Measure pain MKF 2016

Measuring pain Pain is subjective and two patients may report severity differently from each other Despite the fact that pain is specific to each person, patients can usually accurately and reproducibly indicate the severity of their symptom by using a scale Scales enhance the ability of patients to communicate the severity of their pain to health care professionals and the ability of clinicians to communicate among themselves Scales also allow the clinician to assess the effect of medications MKF 2016

Pain scales Scientifically validated pain scales:
Numeric Pain Rating Scale Wong-Baker FACES Scale: for children who can talk Observation-FLACC Scale: for children who can’t talk MKF 2016

Numeric pain rating scale
Pain levels from 0-10 can be explained verbally to the patient using a scale in which 0 is no pain and 10 is the worst possible pain imaginable Patients are asked to rate their pain from 0 to 10 Record the pain level to make treatment decisions, follow-up, and compare between examinations MKF 2016

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 MKF 2016

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 MKF 2016

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 MKF 2016

FLACC scale Score each of the five categories (0-2)
Add the five scores together to get the total (out of 10) The total score can be related to pain intensity Category Score Face Legs Activity Cry Consolability Total Pain intensity FLACC score Relaxed and comfortable Mild discomfort 1-3 Moderate pain 4-6 Severe discomfort/pain 7-10 MKF 2016

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 7 Score 1 2 Score 1 Score 1 2 Score 1 2 MKF 2016

Detailed pain assessments
Detailed pain assessments are useful for treating patients with pain Tools like the PQRST and body charts provide detailed information on location and type of pain as well as quality and response to treatment MKF 2016

PQRST assessment Precipitating and relieving factors Quality Radiation
What makes the pain worse? What makes the pain better? Quality How would you describe the pain? What does it feel like? Radiation Is the pain in one place or does it move around your body? Site and Severity Where is your pain? On a scale of 0-10, how bad is your pain? Timing and Treatment history When did pain start? How often do you get it? What are the patterns of the pain? Is it constant, or does it come and go? Are you or have you been on treatment for the pain? Does it help? MKF 2016

Body charts Use the body chart to indicate areas of pain and take notes on descriptions such as burning, throbbing, or aching throbbing tingling MKF 2016

Take home messages Always ask about your patient’s pain
Though pain is subjective, patients aged 3 and older can accurately assess the severity of their pain Some patients may need some time and education by the healthcare provider to understand how to use the different scales In patients younger than 3 years, objective data can be used to assess pain Pain assessments can be a useful clinical tool in treatment and pain management Effective pain measurement leads to appropriate pain management Health workers should therefore endeavor to accurately measure a patient’s pain MKF 2016

MKF 2016

WHO Analgesic Ladder 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 Review the World Health Organization (WHO) analgesic ladder
Discuss treatment for treat mild, moderate, or severe pain Review additional treatment principles when using opioids MKF 2016

Background The WHO analgesic ladder was introduced in 1986
3-step ladder for adults Updated in 2012 to include 2-step ladder for children Framework for pharmacological management of pain 80-90% of patients are effectively treated using the WHO 3- step approach 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 58 Adapted by Treat the Pain from World Health Organization (accessed 7 November 2013)

Using the WHO ladder for adults
Mild pain - start with a non-opioid, for example with regular paracetamol or non- steroidal anti-inflammatory drug (NSAID), then move up steps if pain remains uncontrolled Moderate - start with a weak opioid, for example, codeine or low-dose morphine Severe - start with a strong opioid, for example, morphine, to control pain early Adjuvants can be used at any step MKF 2016

Step 1 – mild pain: non-opioids
Paracetamol Adult dose: 500mg-1g by mouth every 6 hours; maximum daily dose 4g Note: Hepatoxicity can occur if more than the maximum dose is given per day Paracetamol can be combined with an NSAID MKF 2016

Ibuprofen (NSAID) Adult dose: 400mg by mouth every 6-8 hours; maximum daily dose 1.2g Give with food and avoid in asthmatic patients The maximum dosing limit should be lowered in patients with liver impairment MKF 2016

Diclofenac (NSAID) Adult dose: 50mg by mouth every 8 hours; maximum daily dose 150mg Give with food and avoid in asthmatic patients MKF 2016

Cautions with NSAIDs NSAIDs can cause serious side effects, particularly after using for more than 7-10 days Gastro-intestinal (GI) bleeding or renal toxicity If GI symptoms occur, stop and give H2 receptor antagonist. e.g. Ranitidine Not for use in patients with renal failure MKF 2016

Step 2 – moderate pain: weak opioids
Tramadol Adult dose: mg by mouth every 4-6 hours Start with a regular dose and increase if no response (dose limit: 400mg/day) Use with caution in epileptic cases, especially if patient is taking other drugs that lower the seizure threshold May cause serotonin syndrome in patients on other serotonergic medications MKF 2016

Codeine Adult dose: 30-60mg by mouth every 4 hours; maximum daily dose 240mg If pain relief is not achieved with 240mg/day, move to strong opioid Can be combined with Step 1 analgesic Give laxative to avoid constipation unless patient has diarrhoea Genetic variability can lead to variable rates of metabolism which may make codeine ineffective or lead to excessive side effects MKF 2016

Low-dose morphine Some palliative care experts recommend using low-dose morphine in step 2 because it is associated with fewer side effects compared to other weak opioids MKF 2016

Step 3 – severe pain: strong opioids
Morphine “Gold standard” against which other opioid analgesics are measured When used correctly, patients don’t become dependent or addicted, tolerance is uncommon, and respiratory depression doesn’t usually occur MKF 2016

Less commonly used strong opioids Fentanyl Oxycodone Hydromorphone Methadone MKF 2016

Morphine Adult starting dose: 2.5–20mg by mouth every 4 hours depending on age, previous use of opiates, etc. Patients changing from regular administration of a Step 2 opioid: 10mg by mouth every 4 hours If the patient has experienced weight loss from sickness or has not progressed onto Step 2 analgesics: 5mg by mouth every 4 hours Frail or elderly patients: 2.5mg by mouth every 6 to 8 hours due to the likelihood of impaired renal function MKF 2016

Morphine is available as immediate-release or sustained- release formulations Immediate-release Dose every 4 hours Use to titrate starting dose and treat breakthrough pain MKF 2016

Sustained-release (or slow-release) Dose every 8-24 hours, depending on the formulation After determining daily dose with immediate-release morphine, can change to sustained-release morphine, being careful to adjust dose as needed to maintain the total daily dose Priority should be given to making immediate-release formulations available MKF 2016

Morphine Increase dose gradually until pain is controlled The correct morphine dose is the one that gives pain relief without side effects: there is no ‘ceiling’ or maximum dose MKF 2016

MKF 2016

Caution: pethidine Pethidine is not suitable for patients with chronic pain It has a faster onset of action and a shorter duration of action than morphine and needs more frequent dosing: every 2–3 hours Pethidine is metabolised to norpethidine which has side effects inducing central nervous system excitability including mood changes, tremors, myoclonus (sudden jerking of the limbs) and convulsions Pethidine was removed from the WHO essential medicines list in because it was judged to be inferior to morphine due to its toxicity on the central nervous system and is generally more expensive than morphine MKF 2016

Treatment principles By the mouth: Use the oral route whenever possible By the clock: Administer analgesics according to regular schedule based on duration of effectiveness rather than “as needed”, except when titrating dose By the ladder: Use the WHO analgesic ladder. If after giving the optimum dose an analgesic does not control pain, move up the ladder; do not move sideways in the same level By the patient: The right dose is the one that relieves pain. Titrate the dose upwards until pain is relieved or side effects prevent moving up further MKF 2016

Stopping or changing opioids
When stopping an opioid, reduce daily dose by 25% each day to avoid symptoms of withdrawal When changing from one opioid to another, be mindful of the need to convert doses Check reference materials or consult an expert MKF 2016

Opioid Pharmacokinetics
Dosing – First Order Kinetics Opioids tCmax t1/2 IV 15 mins 4 Hours SC / IM 30 mins PO / PR 60 mins Changing Routes of Administration PO / PR IV / SC / IM Epidural Intrathecal 3 1 0.1 0.01 MKF 2016

... Equianalgesic Dosing for Opioids
Oral / Rectal Dose (mg) Analgesic Parenteral IV/SC/IM Dose (mg) 150 Meperidine 50 Tramadol - Codeine 15 Hydrocodone Morphine 5 10 Oxycodone Oxymorphone 3 Hydromorphone 1 2 Levorphanol Fentanyl 0.050 TRANSDERMAL FENTANYL Morphine 50mg PO in 24 hrs ≈ Fentanyl 25 mcg transdermal patch q 72 hrs MKF 2016

Key treatment principle: prophylactic laxatives
All patients on opioids are at high risk for constipation, and laxatives should be ordered unless contraindicated MKF 2016

Take home message The WHO ladder, an important tool of managing pain, can effectively treat 80-90% of the patients at this facility For non-responsive pain, please refer to a pain specialist MKF 2016

Practical Assessment Esther, a 28 year-old woman with cancer, reports a pain score of 5 out of 10. Which medicines would you consider prescribing? A. Codeine B. Tramadol C. Low-dose morphine D. Any of the above If you prescribe low-dose morphine, what is Esther’s starting dose? 2.5mg every four hours What other prescriptions must be written at the same time? Laxatives MKF 2016

Thank you Palliative Care Team
MKF 2016

Pain Management in Palliative Care

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