1. Welcome to St Clare Hospice

2. l Welcome l Pain control: getting it right l Hospice in-patient care l Hospice Day Therapy l Hospital Palliative Care l Community Palliative Care l Case Studies l Close Outline

3. Pain control: getting it right john.zeppetella@stclarehospice.org.uk

4. 53% all stages of disease 53% all stages of disease 59% of patients on active anticancer treatment 59% of patients on active anticancer treatment 64% of patients with metastatic, advanced or terminal disease 64% of patients with metastatic, advanced or terminal disease 33% of patients who had been cured of cancer 33% of patients who had been cured of cancer More than 33% graded pain as moderate or severe More than 33% graded pain as moderate or severe Scope of the problem van den Beuken-van Everdingen et al. 2007

5. Physical Physical Social Social Psychological Psychological Spiritual Spiritual Total pain

6. Cancer pain Acute painRecent onset, transient, identifiable cause Acute painRecent onset, transient, identifiable cause Chronic pain Chronic painPersistent or recurrent pain, beyond usual course of acute illness or injury Breakthrough pain Breakthrough painTransient pain, severe or excruciating, over baseline of moderate pain

7. Pathophysiology Neuropathic pain Pain initiated or caused by a primary lesion or dysfunction in the peripheral or central nervous system Nociceptive pain Pain caused by an inflammatory or non-inflammatory response to a noxious stimulus

8. NOCICEPTIVE PAIN SOMATIC SUPERFICIAL VISCERAL DEEP Pathophysiology

9. NEUROPATHIC PAIN NERVE INJURY PERIPHERAL NERVE COMPRESSION SYMPATHETICALLY MAINTAINED CENTRAL Pathophysiology

10. Pathophysiology CharacteristicsMechanismsExamples Somatic Constant, aching, gnawing. Well localised Activation of nociceptors in cutaneous or deep tissues Skin metastases Visceral Constant, aching, poorly localised often referred Activation of nociceptors due to infiltration compression Pancreatic cancer Lung/liver metastases Neuropathic Paroxysmal, shooting or shock-like pain. Background of burning or constriction Spontaneous and paroxysmal discharges in PNS and CNS Tumour compression Post-surgical incision

11. Multiple pains No of patients No of pains

12. Aetiology % Patients

13. Site Site Quality Quality Exacerbating factors Exacerbating factors Relieving factors Relieving factors Temporal patterns Temporal patterns Assessment Exact onset Exact onset Associated symptoms Associated symptoms Interference with activities of daily living Interference with activities of daily living Response to analgesics Response to analgesics Foley KM. Oxford Textbook of Palliative Medicine 2004

14. Assessment tools Pain charts Visual analogue scales Pain diaries Questionnaires

15. Clinicians Clinicians Patients Patients Health care system Health care system Barriers

16. Managing cancer pain Hormone therapy Analgesics Chemotherapy Surgery Radiotherapy Anaesthetic procedures Adjuvant analgesics