Palliative care: pain management

What is pain

Oxford dictionary: highly unpleasant physical sensation caused by illness or injury

International association for the study of pain: An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage

5 A’s of Cancer Pain Outcomes

NCCN recommendations for goals of pain therapy

Analgesia -> take the pain away

Activities -> preserve performance status

Adverse Effects -> reduce side effects

Aberrant Behavior -> impulse control, addiction

Affect -> how pain interacts with mood of the pt. Emotional status of patient due to pain

WHO pain ladder

opioids - types

Morphine

Convenient, morphine syrup is not a controlled drug in Singapore -> tabs are CD

Active morphine-6-glucuronide is renally eliminated

Causes somnolence

Fentanyl

A synthetic opioid that is up to 50x stronger than heroin, 100x stronger than morphine - high risk of OD

Very short half life - easy to titrate quickly

Fentanyl and other synthetic opioids are the most common drugs involved in overdose deaths. Can be deadly in small doses.

opioids - selecting pain regimen

opioids - opioid equivalences

opioids - opioid prescribing footnotes (FYI)

opioids - pt case → opioid conversion

opioids - fentanyl patch

o   Key consideration for conversion of other opioids to fentanyl

§  Patient’s opioid tolerance!

·         If patient is not tolerant, OD is very possible

o   Counselling is important for patients to monitor for adverse effects or Sx of OD + corrective actions

·         For purpose of exams, if patient is not opioid tolerant, they shouldn’t be on fentanyl

opioids - pt case → fentanyl patch conversion

opioids - methadone

methadone - prescribing footnotes (FYI)

opioids - ketamine

tolerance vs dependence vs addiction

CDC Clinical Practice Guideline for Prescribing Opioids for Pain

opioids - adjuvants

Gaba acting anticonvulsants -> nerve pain

• Gabapentin, Pregabalin

SNRIs

Tramadol: 2 for 1? -> but has dose ceiling

Lidocaine patches -> not really used. May be good for nerve pain

what is palliative care

End of life syndromes - dyspnea

Common in lung cancer patients

Non-pharmacologic approaches should be considered

Oxygen therapy may be helpful in some cases, remember to consider if had previous bleomycin chemotherapy

Morphine prn is routinely seen prescribed at NUH, titrated to respiratory rate -> to control how fast they breath

End of life syndromes - secretions

Glycopyrrolate sometimes prescribed (but exempt in Singapore)

Anticholinergics used but carefully weigh toxicities and patient preferences

Use anti-secretory agents

End of Life Syndromes - Agitation/Delirium

Pharmacists should always look for medication related causes or contributors to delirium and look for alternatives or consider deprescribing

Antipsychotics seen as an option of last resort due to questionable efficacy and undesirable AEs, although anecdotally atypical antipsychotics are increasingly being used to perhaps safer effect

Usually haloperidol, benzos to calm them down

End of Life Syndromes - Bowel Obstructions

consider gastric tube

End of Life Syndromes - Other Common Ailments

Anorexia/cachexia

Persistent nausea

Chronic diarrhea/constipation

Insomnia/over-sedation

Wound care/pressure ulcers 

palliative care - drugs used