Pain Management in Palliative Care

Dr.Raman Swathy VamanDistrict Programme Manager

National Health MissionAarogyakeralam Kasaragod

WHY AM I HERE TODAY ?????

NOT FOR THIS

"Pain is a more terrible Lord of Mankind than even

Death itself"

Albert Schweitzer (1875-1965)

Dr.Robert Twycross

Pain is what the patient says Hurts....

Evolution of Pain theories

Rene Descartes Dr. Henry Beecher

Ronald Melzack Patrick Wall

IASP Definition

"Pain is an Unpleasant, Subjective, Sensory and Emotional experience associated with actual or potential tissue damage or described in terms of

such damage"

Pathophysiology

Types of pain

• Acute• Chronic

Pain

NeuropathicNociceptive

Sympathetic

Capsular Soft TissueBoneCardiac

CentralPeripheralSomaticVisceral

Bowel

Causes of pain in C/c illness

Disease Related

Soft tissue infiltrationVisceralNerve compression / InfiltrationBone spreadMuscle spasmLymphoedemaRaised ICT

Treatment Related

Post op Scars and adhesionsRadiotherapy FibrosisChemotherapy neuropathy

Causes of pain in C/c illness

Debility RelatedConstipationPressure soresBladder spasmStiff JointsPost Herpetic neuralgia

Co MorbiditiesSystemic IllnessesArthritisTrauma

Total Pain

Psychosocial Distress Physical Distress

Spiritual Distress

Assessment of Pain

1) Visual Analogue Scales (VAS)

2) CategoricalVerbal Rating Scales (VRS)

3) Categorical Numerical Rating Scales (NRS)

For Adult Paients

VAS

NO PAIN WORST PAIN

VRS

None

Mild

Moderate

Severe

NRS

For Childrens

McGill Pain Questionnaire

Brief Pain Inventory

The Abbey Pain Scale

Management of Nociceptive pain

WHO Analgesic Ladder

Continued Psycho Social Support

Non Opioids• Paracetamol• Aspirin• NSAIDs

Weak Opioids

• Tramadol• Codeine• Dihydrocodeine• Dextropropoxephene• Pentazocin

Strong Opioids

• Morphine• Pethidine• Buprenorphine• Fentanyl• Methadone• Oxycodone

Adjuvants / Co-Analgesics • Anti emetics• Anti depressants• Anti convulsants• Anti spasmodics• Anti biotics• Muscle relaxant• Anxiolytics• Sedatives• PPI/ Antacids• Bisphosphonates

Clinical Situation Adjuvant

Headache due to Cerebral edema Dexamethasone

Painful wounds Antibiotics

Liver Capsule pain Dexamethasone

Gastric mucosa irritation PPI

Gastric distension Dimethicone＋Metoclopramide

Skeletal muscle spasm Diazepam, baclofen

Cardiac pain Nitrates, Nifedipine

Oesophagealspasm Nitrates, Nifedipine

Intestinal Colic Hyoscine

Practical Guidelines

Practical aspects of using strong Narcotics

• 1st Line -- Morphine

• 2nd line -- Oxycodone , Fentanyl, Hydromorphone

• 3rd Line -- Methadone

Morphine Trial

ADDICTIONADDICTION TERMINAL STAGETERMINAL STAGE

COPDCOPD

By the MouthBy the Clock

By the LadderFor the IndividualAttention to detail

REVIEW, REVIEW,REVIEW

Common Opioid Side effects

Drowsiness & Cognitive ImpairmentHallucinations or DeliriumMyoclonusConstipationNausea & VomitingPruritusOpioid withdrawal symptomsOpioid induced increase in generalised

pain

Warning Signs of Morphine toxicity

DrowsinessConfusionHallucinationVomitingMyoclonusPinpoint pupilUrinary retention

Opioid Resistant Cancer Pain

Opioid Conversion Rules

Management of Neuropathic Pain

1st LineWHO Analgesics/ OpioidsAntidepressantsAnticonvulsantsCorticosteroidsRadiotherapyChemotherapy

2nd LineKetamineLignocaine infusionSpinal analgesiaTENSNeurolytic proceduresCaspaicin

Non Pharmacological management

Complementary therapiesAcupunctureReflexologyTouch therapyAroma therapyArt therapyMusic therapyHypno therapy

Other non pharmacological interventions

PositioningReassuranceGood communicationDiversional therapyPsychological supportRelaxation therapyJoint mobility- Passive and ActiveSpiritual Counselling

Break through pain

End of Dose Pain

Any Questions

?

Lets bring the smiles back on their faces.......

Wishing you a l l the very BEST** in your Personal , Profess iona l & Academic facets o f l i f e . . . . . . . . . . . . . . . .

Thanking You . . . . . . . . . . . . .

BEST - - B es t Extent in the S i tuat ion and T ime frame