1. Pain Management In the Palliative Care Setting M. Thomas Beets MD

2. Objectives: Recognize the importance of cultural differences when developing pain management approaches to patients and families Have more insight into the multimodality approach to pain management Identify symptoms occuring in palliative care patients in order to evaluate the various treatment options Understand ongoing research in pain management of the palliative patient

3. Three Steps Assess the cause of the pain (may be multiple causes) Treat each type of pain Reassess continuously, expecially if pain uncontrolled

4. Categories of Pain (P)Physical (A)Emotional (I)Social or interpersonal (N)Spiritual or existential

5. Assessment History Character of the pain Physical Pain assessment scale Lab Imaging

6. Bone Pain Intensifies on movement (Incident pain) Tender to palpation Deep and aching

7. Neuropathic Pain Shooting Burning Paresthesias-tingling Stabbing Scalding Often follows sensory nerve distribution May have allodynia (pain from light touch)

8. Raised Intracranial Pressure Generalized or posterior head pain Nausea

9. Visceral Pain Spasms Cramping Colicky Consider anticholinergics

10. Opioids Respiratory depression not usually clinically significant Physical dependence is not addiction Tolerance verses disease progression Very wide effective dose range Are effective by mouth Rare to have euphoria in palliative patients

11. Step 3, Severe Pain Morphine Hydromorphone Methadone Fentanyl Oxycodone + Nonopioid analgesics + Adjuvants Step 2, Moderate Pain Acet or ASA + Codeine Hydrocodone Oxycodone + Adjuvants Step 1, Mild Pain Aspirin (ASA) Acetaminophen (Acet) Nonsteroidal anti- inflammatory drugs (NSAIDs) + Adjuvants WHO 3-Step Ladder WORLD HEALTH ORGANIZATION

12. Equianalgesic Doses of Opioid Analgesics PO, SLParenteral 100Codeine60 -Fentanyl0.1 15Hydrocodone- 4Hydromorphone1.5 150Meperidine50 10Methadone5 15Morphine (MS Contin, Morphine, Kadian, Avinza, MSIR, Roxanol) 5 10Oxycodone (Percodan, Percocet, Oxycontin, Oxyfast, OxyIR) - 1mcg/hr Fentanyl = 2 mg morphine/24 hours Education on Palliative and End of Life Care 2007

13. Equianalgesic Example 40 yr old male, Lung Ca & Bone mets, severe pain Morphine Equivalent Current:MS Contin 400 mg TID=1200 mg/24 hrs Duragesic 2 100 mcg patches= 400 mg/24 hrs Roxanol 20 mg/mlx 10 doses of 1ml= 200 mg/24 hrs Morphine Equivalent Total (Oral)=1800 mg/24 hrs Equianalgesic Dose, one-third for IV use=600 mg/24 hrs IV/Subcut Morphine Rate, divide by 24 hrs=25 mg/hr

14. Principles Work with oral morphine equivalents Give around the clock Limited cross-tolerance Opioid rotation Begin with low dose In elderly begin with ½ the usual dose Titrate Q 4 hr booster is 10% of 24 hr dose

15. Principles Avoid meperidine-metabolized to normeperidine with 15-20 hr ½ life Avoid pentazocine-inhibits analgesia of morphine Avoid IM Treat constipation-softening agent and stimulant, avoid bulking agents

16. Principles Severe liver disease-opioids and benzodiazepines will have delayed metabolism (avoid methadone and acetominophen)

17. Bone or Soft Tissue Pain Opioids NSAIDS Steroids Calcitonin Radiosotopes biphosphonates

18. Neuropathic Pain Tricyclic antidepressants Anticonvulsants Local anesthetics Baclofen Capsaicin

19. Raised ICP Steroids

20. Visceral Pain Oxybutinin 5-10 mg po tid Hyoscyamine 0.125mg 1-2 po or sl q 4 hrs prn Transdermal scopolamine Glycopyrrolate 0.2 mg IV, subcut q 4 hrs

21. Other modalities Distraction Meditation Massage TENS Acupuncture

22. Other Pearls Ketamine Steroids XRT Most opioids are effectively absorbed from the rectum Transdermal, transmucosal, subcut, IV Epidural or intrathecal analgesics Ketorolac Lorazepam

23. Bibliography EPEC (Education in Palliative and End-of-life Care), Education of all healthcare professionals on the essential clinical competencies in palliative care. www.epec.net www.epec.net Storey P, Knight C, UNIPAC Three: Assessment and Treatment of Pain in the Terminally Ill. 2 nd ed. New York:Mary Ann Liebert, 2003. WHO Ladder: Cancer Pain relief and Palliative Care. Technical Report Series 894. Geneva: World Health Organization; 1990.