Pain Management

In the Palliative Care Setting

M. Thomas Beets MD

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

Three Steps

• Assess the cause of the pain (may be multiple causes)

• Treat each type of pain

• Reassess continuously, expecially if pain uncontrolled

Categories of Pain

• (P)Physical• (A)Emotional• (I)Social or interpersonal• (N)Spiritual or existential

Assessment

• History• Character of the pain• Physical• Pain assessment scale• Lab• Imaging

Bone Pain

• Intensifies on movement (Incident pain)• Tender to palpation• Deep and aching

Neuropathic Pain

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

Raised Intracranial Pressure

• Generalized or posterior head pain• Nausea

Visceral Pain

• Spasms• Cramping• Colicky

• Consider anticholinergics

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

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 LadderWORLD HEALTH ORGANIZATION

Equianalgesic Doses of Opioid AnalgesicsPO, SL Parenteral

100 Codeine 60

- Fentanyl 0.1

15 Hydrocodone -

4 Hydromorphone 1.5

150 Meperidine 50

10 Methadone 5

15 Morphine (MS Contin, Morphine, Kadian, Avinza, MSIR, Roxanol)

5

10 Oxycodone (Percodan, Percocet, Oxycontin, Oxyfast, OxyIR)

-

1mcg/hr Fentanyl = 2 mg morphine/24 hours

Education on Palliative and End of Life Care 2007

Equianalgesic Example

• 40 yr old male, Lung Ca & Bone mets, severe pain

Morphine EquivalentCurrent: MS Contin 400 mg TID =1200 mg/24 hrs

Duragesic 2 100 mcg patches = 400 mg/24 hrsRoxanol 20 mg/ml x 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

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

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

Principles

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

Bone or Soft Tissue Pain

• Opioids• NSAIDS• Steroids• Calcitonin• Radiosotopes• biphosphonates

Neuropathic Pain

• Tricyclic antidepressants• Anticonvulsants• Local anesthetics• Baclofen• Capsaicin

Raised ICP

• Steroids

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

Other modalities

• Distraction• Meditation• Massage• TENS• Acupuncture

Other Pearls

• Ketamine• Steroids• XRT• Most opioids are effectively absorbed from the

rectum• Transdermal, transmucosal, subcut, IV• Epidural or intrathecal analgesics• Ketorolac• Lorazepam

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

Storey P, Knight C, UNIPAC Three: Assessment and Treatment of Pain in the Terminally Ill. 2nd ed. New York:Mary Ann Liebert, 2003.

• WHO Ladder: Cancer Pain relief and Palliative Care. Technical Report Series 894. Geneva: World Health Organization; 1990.