1. Let’s Talk About Pain Karen Cox-Seignoret M.B.,B.S., M.R.C.G.P.

2. What is pain?

3. Pain is…  An unpleasant sensory and emotional experience caused by actual or potential tissue damage  Any unpleasant bodily sensation; mental suffering

4. Physical Pain

6. Total Pain

7. WHAT’S DIFFERENT ABOUT CANCER PAIN?

8. The meaning of the pain

9. The Problem of Pain  Pain is what the patient says hurts  75% of patients with advanced cancer experience pain  Worldwide half of those dying are in uncontrolled pain  Cancer pain can be relieved in 70-90% using a simple opioid regimen.

10. What Causes Pain?  Painful stimuli act on specialized nerve endings (nociceptors)  Inflammatory cells, neurotransmitters and other chemicals are released  Messages are sent to the spinal cord and thence to the thalamus, hypothalamus and cerebral cortex

11. Types of pain  Somatic/visceral usually opioid sensitive  Bony usually NSAID sensitive  Neuropathic may be poorly responsive to opioids try adjuvant agents 40-50% cancer pain

12. Pain Assessment  Assess the cause of the pain: related to the cancer, related to the treatment, unrelated to either  Assess the type of the pain (somatic, visceral, bony, neuropathic)  Assess pain severity

14. Where to start?

15. Or these?

16. Immediate Release Morphine

17. Or maybe these?

19. WHO Analgesic Ladder

21. Drugs Step 1 Non-Opioids e.g. paracetamol, NSAID’s Step 2 Weak Opioids e.g. codeine, dihydrocoedein, tramadol Step 3 Strong Opioids e.g. morphine, diamorphine, fentanyl, oxycodone, methadone

22. Adjuvant Analgesics Are not analgesics in their own right, and are used primarily for other indications, but can produce analgesia in certain circumstances.

23. Adjuvant Analgesics Antidepressants e.g. amitriptyline Anticonvulsants e.g. carbamazepine, sodium valproate, gabapentin, pregabalin. Membrane stabilizers e.g. flecainide, mexilitine Corticosteroids

24. Locally Available Opioids

25. Codeine  Weak opioid  Effective as a cough suppressant and antidiarrhoeal agent  Compounds: panadeine, panadeine F, paracodeine.

26. Tramadol  Less constipation and respiratory depression than Morphine  May have a role in neuropathic pain  Trabilin, Tramacet

27. Pethidine  NOT appropriate for chronic pain  Accumulation of metabolites with adverse CNS side effects  Duration of action 3-4 hours only

28. NIL IN STOCK

30. Global Consumption of Morphine, 2010 **Austria’s consumption includes use of morphine for substitution therapy Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2012 mg/capita 152 countries Global Mean 5.9912 T&T 1.54 TT’s morphine use per capita: 75% below world average!

32. Myths  Patient will get hooked on morphine Addiction (psychological dependence), is rare (4 cases per 12,000)when opioids are used for severe pain.

33. Myths  Dangerous respiratory depression is likely  If started too early, morphine will not be effective later,when really needed  Morphine will speed up death

34. Strong Opioids “Exist to be given, not merely to be withheld”

35. Guidelines for Opioid Use WHO Guidelines*  BY MOUTH  BY THE CLOCK (regularly and not prn)  BY THE LADDER WHO (1986) Cancer Pain Relief. WHO, Geneva WHO (1996) Cancer pain Relief : with a guide to opioid availability. WHO Geneva.

36. Guidelines for Opioid Use  A ddress breakthrough pain  A nticipate Nausea -antiemetic e.g. metoclopramide for 4-5 days  A nticipate Constipation - stimulant laxative e.g. senna or bisacodyl

37. Guidelines for Opioid Use  Anticipate pain – give analgesia 30min before an activity known to cause pain  Review dosing regularly!

38. Difficult to control pain Review the cause Is it opioid sensitive? DO NOT INCREASE THE OPIOID DOSE IF NOT. Consider adding adjuvant agent, Consider other options - surgery, radiotherapy, bisphosphonates.

39. Non-Drug Therapies  TENS  Nerve blocks  Physical therapy  Radiotherapy  Complementary & Alternative Therapies – Acupuncture, relaxation techniques, hypnotherapy, aromatherapy massage.

40. The Declaration of Montreal Access to Pain Management is a Fundamental Human Right. Governments are obliged to establish laws, policies and systems to promote adequate pain management.

42. “I must tell him, the doctor, that he must think of something else. It is impossible, impossible to go on like this.” Leo Tolstoy, the death of Ivan Illych

43. THANK YOU