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Pain and Symptom Management
Fran MacIvor Locum Consultant, Palliative Medicine
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Pain basics, and a little bit about nausea and constipation
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Important things from today….
Pain – its not all the same Importance of details How to prescribe strong analgesia
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Types of pain Visceral pain Nerve TOTAL PAIN Musculo-skeletal
(somatic) Bone pain
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Assessment Nature Pattern (Breakthrough? End of dose? Incident?)
Severity / intensity (see scales*) Effect of current analgesia What do they think is the cause?
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Visual pain scales
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Analgesia – the basics The WHO ladder
Sorts out 80 – 90% of pain if used properly
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Case Mr. B, 60 y.o. man Lung cancer Invasion of ribs on right
Tramadol 100mg QDS, paracetamol 1g QDS Still in pain….
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Initiating Step 3 - Opiates
Initiating Opiates
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Introducing opiates – a safe start…
Start with simple morphine unless there is a reason not to Use prn doses of short acting morphine (oramorph) initially to assess a) effectiveness b) side effects? Calculate total dose of oramorph used over previous 24 hours Divide total in two and give as long acting MST BD
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Give 1/6th of total 24 hour dose, as required for breakthrough, up to once every hour if needed
Next day, look again at total breakthrough used and titrate up long-acting MST appropriately Remember the breakthrough dose may need to be increased too REMEMBER S/C MORPHINE IS 2X AS STRONG AS ORAL ie. HALVE THE ORAL DOSE
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Reasons for caution…… Signs of opiate toxicity Drowsy Confused
Myoclonic jerks Hallucinations (visual peripheral especially) Nausea Pupils Respiratory depression
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Case Mrs G. 90 year old Pathological fracture of hip
Dementia, NH resident Communication difficult What issues might there be in providing adequate pain relief?
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Examples of adjuvants Anticonvulsants Antidepressants Steroids
Muscle relaxants Bisphosphonates Chemo / radiotherapy Surgery
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Opiate switching Alternatives to morphine; Oxycodone Hydromorphone
Fentanyl / Alfentanil Diamorphine Methadone
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Nausea and Vomiting Common causes are common! Drugs Treatments
Tumour type and position
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Constipation Poor oral intake does not mean no poo Immobility Drugs
Disruption of habit Altered gut function Always prescribe a laxative with opiates
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Factors associated with worse experience of nausea/vomiting
Tumour type Female Younger than 50 History of travel sickness Anxious personality
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Causes of nausea and vomiting
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Put right what you can… Rehydrate
Treat blood abnormalities (Ca, Urea etc.) Stop offending drugs GET BOWELS MOVING
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Anticipatory/anxiety
Drugs (v. simplified) Main cause First choice Bowel problem Metoclopramide/Domp. (ondansetron) Swelling Steroid Abnormal blood/ Drugs Haloperidol Chemo/radiotherapy Ondansetron/Aprep. Anticipatory/anxiety Lorazepam All above/ Don’t know Levomepromazine
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Help with symptoms HPCT (Tay-UHB.palliative@nhs.net)
Palliativedrugs.com
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