9-11 Palliative pain

Explain the philosophies of palliative care and

the role of the team members

Describe causes and consequences of pain in

the palliative population

Discuss etiology and assessment of malignant

pain

Demonstrate how assessments are used in a

clinical setting

What is palliative care?

A specialized medical care that focuses on improving the quality of life for patients with serious illnesses. It aims to provide relief from symptoms, pain, and stress, while also addressing emotional, social, and spiritual needs ( holistic) Palliative care can be provided alongside curative treatment and is not limited to end-of-life care.

What did the Temel Study show?

Lung cancer patients into 2 groups

Proved that Palliative care improved QoL, Mood, Survival (by 3 more months)

When to consider palliative care

If you are not surprised if patient died in next year

If you are surprised if they passed in a year, may be an option if they are symptomatic

misconceptions of palliative care

Death imminent by everyone

Only those in C level of care go into ICU? (What public thinks)

palliative care is % communication

99

What does TPCU stand for?

% of pain syndromes can be controlled

85

sources of pain in palliative pts

Terminal - cancer

Pre existing pain condition - fibromyalgia, chronic pain, arthritis, diabetic neuropathy, migraine, sciatica

Pain is clinically sig symptom of cancer - what %?

59% of those receiving tx

64% of patients with advanced or metastatic disease

Causes of cancer pain

Invasion of tissue - nociceltive from somatic or visceral pain

Invasion of nerves

Paraneookastic phenomena

Altered nerve conduction

Indirectly - constipation, obstruction, fracture

Cancer pain from tx

Chemo - neuropathy

Radiation - burns, pain flare

Sx - infection, wound, phantom pain

Barriers to good pain control

Family

Compliance issues

Financial concern

Complaining to HCP

HCP

Skills, fear of addiction, reprimand, do not ID multidimensional pain or do not understand pain

Cancer pain is complex and involves TOTAL PAIN

Phys

Behaviour

Cognitive

Emotional

Spiritual

Interpersonal

Residual chronic cancer pain in survivors %

33 - 40

Reduces QoL

PPS palliative performance status

Assesses change in prognosis - better? Worse?

Mostly revolves around function and impact on daily activities

ESAS-r Graph

daily assessment of FEELINGS of patient - comes with a diagram of body and patient indicates what portion is affected by (condition) on a scale from 0-10

The symptoms are then plotted on a graph daily to visualize improvement/worsening

CAGE

Asses addictions

Cut down on addiction

Annoyed by criticism of your addiction?

Guilty feelings about addiction?

Eye-opener : use addiction method to get rid of addiction hangover or withdrawal

/4 (anything 2 or over is positive cage)

Folate is mini-mental state exam 1975

Cognition screen - free to use!

Other Assessments of cognitions

CAM (confusion assessment method)

Mini-Cog (clock drawing and memory)

BOMC (blessed orientation memory concentration test)

Executive function test

SLUMS or MOCA

ECS-CP

Edmonton Classification System for Cancer Pain

Addresses multi factorial approach

MOA of pain

Incident pain

Psych distress

Addictive behaviours

Cognitive function

N I P A C

What ECS-CP uses to identify different parts of pain

Mechanism of pain in ESC-CP

Incident pain in ESC-CP

Psychological distress in ECS-CP

Addictive Behaviour in ECS-CP

cognitive function in ECS-CP

What is Nx Ix Px Ax Ci

Unable to assess pain type, or if incident pain,

psychological or addictive components present because of cognitive impairment. (eg. Patient admitted in delirium)

What is No

no pain present, non-malignant pain only (eg. arthritis), or

no cancer diagnosis.

what is Ne Ii Pp Aa Co

Has neuropathic and incident pain. Psychological

component to pain expression and history of addictions.

What is Nc Ii Po Ao Co

Has nociceptive pain & incident pain, but no other pain

syndromes

Explain how cancer pain is managed based on

the WHO analgesic ladder

Discuss the analgesics used in malignant pain at

each step of the WHO analgesic ladder

Review the properties of methadone and identify

how this agent may be used in cancer pain

Describe adjuvant and non-pharmacologic

options available

Apply knowledge of assessments and analgesics

to patient case

Who ANALGESIC SCALE

1-3 mild (non opioid)

4-6 moderate (opioid + non opioid, adjuvant if needed

7-10 severe (opioid + non opioid, adjuvant anything that works)

Mild pain

Tylenol NSAIDs plus minus adjuvants

moderate pain

weak opioids (codiene, tramadol)

Adjuvants

severe pain opioids

morphine

Hydromorph

issue with step two of who analgesic ladder

Insufficient evidence to support/refute Step 2

opioids (eg. codeine) are superior to NSAIDS

Can be omitted in rapid progressing pain

Cancer pain medications (general info)

regular Rx analgesics ATC

Laxatives needed if opioid use

P.O. preferred

Why is P.O. preferred?

Cheap

Easiest admin

No specialized pharmacy

No risk of infection (unlike IV)

Less painful (unlike IV)

when is P.O. not achievable?

Malabsorption in gut

Short bowel, obstruction

NV

Pt is delirious or unresponsive

breakthrough pain is usually what % of TDD

10%

Tylenol 4g

Only use short term in healthy adults

Tylenol 3g

long term use in healthy adults (longer than 7 days)

Tylenol 2g or avoid

Heavy alcohol use, malnutrition, older, liver disease, interacting meds

Maybe avoid

Are NSAIDs are effective as weak opioids?

Yes

Usually for mild cancer pain

Bone pain efficacy is inconsistent

What adverse effects to look out for in Nsaids

elderly pop : GIB, kidneys

are opioids used only at end of life?

Increased survival - not shown to shorten life if used appropriately

opioids are sedating and they can’t drive

Sedating effects can be overcome over a few days (tolerance can be built)

Do opioid users get addicted easily?

Not if using appropriately - increases May be due to tolerance

If opioids started to early there are no more options at end of life?

Pain may not increase at end of life. can switch agents

Codiene is 1/10 as potent as morphine?

Yes

How is codiene metabolized

Via cyp2d6

Into morphine

Watch for genetic polymorphism

Max codiene dose

300-400mg

tramadol MOA

Weak opioid agonist and inhibitor of NE, agonist on 5HT reuptake

where is tramadol metabolized

Liver

maximum dose of tramadol

400-600mg qd

Tramadol interactions with medications and conditions

TCA and SSRI (seizure risk)

Seizure disorder, hepatic, renal impairment

what strong opioids are never used first line?

Fentanyl and methadone

Opioid AE that can gain tolerance PRUNS

Pruritus (histamine release)

Resp depression

Urinary symptoms (histamine)

Nausea

Sedation (histamine)

is fentanyl 100x stronger than morphine?

Yes

is fentanyl available orally?

NO - only patches, inj, SL, intranasal

Inj works quickly and short lasting - use 15 minutes prior to something that is painful

conversions of fentanyl patch (fyi?)

SL fentanyl

Can use inj SL by holding under tongue as long as possible

Expensive

methadone properties

SLAR

Synthetic

Lipophilic - gets to tissues well

Absorbed well orally (in GIT)

Rapid onset (2-3H)

Renal elimination of methadone is dependent on

Urine pH

NO ACCUMULATION IN RENAL FAILURE (so can use in renal failure)

what % is eliminated fecally?

60%

issue with dosing methadone

Unpredictable half-life (eliminated anywhere between 15 and 60 hours)

From this, can have a DELAYED OVERDOSE (ISSUE)

Why is methadone good in neuropathic pain?

useful in neuropathic pain without neurotoxicities

Works on

μ, k & δ (agonist)

NMDA antagonist

NE and 5HT reuptake

Pros of Methadone

Cheap

Good for neuropathic pain

Lower neurotoxicity due to NMDA antagonist

Metabolism of methadone

Cyp3a4

Cyp1a2

Cyp2d6

methadone and QTc interval

If in end of life - not concern

If not in end of life - concern because you can experience sudden death

Dose related especially in high doses (300-600mg qd)

Because of methadone’s unpredictable half life, can have unpredictable effect on QTc as well

what decreases Methadone?

Antiretrovirals: Nevirapine, Ritonavir

◦ Phenytoin ◦ Carbamazepine ◦ Dexamethasone ◦ Rifampin ◦ Spironolactone ◦ Alcohol/tobacco

what increases Methadone?

Cimetidine

◦ Omeprazole

◦ Ketoconazole

◦ Fluconazole

◦SSRI’s

◦ Verapamil

◦ Ciprofloxacin

◦ Macrolides

Who is on methadone therapy

highly tolerant to other agents

Neuropathic pain

For incomplete cross tolerance

Methadone as co analgesic

Low dose methadone can be used on top of reg opioid

May not get full benefit of methadone and if toxicity occurs hard to determine origin

Disadvantages of methadone

Unpredictable half life

QTc interval

Rectal and injectable not commercially available

Whenever naloxone is administered

Call ambulance

When patient is dying

Breathing rate will change - do not mistake for opioid toxicity, if opioid is reversed then they will die in a lot of pain

Gabapentin and Pregabalin

Must be tapered, cannot discontinue stat

Just use gut for tapering… no guide for it

Morphine and ketamine used together equals

Morphine and ketamine used together = methadone bc ketamine works as NMDA antagonist

Why is Effexor not used often for neuropathic pain?

Hard to d/c and has profound withdrawal effects like electric shocks

what antidepressants are not used anymore for neuropathic pain?

carbamazepine , valorous acid, phenytoin (all seizure meds)

why is dexamethasone CS of choice

6.7 times more potent than prednisone

Less mineralcorticosteoid effects like fluid retention

prednisolone causes less————- than dexamethasone

Proximal myopathy

when is taper needed for CS?

If taking longer than 2 weeks

risk of NSAID use with CS

Gastric ulceration

Buprenorphine in cancer

For chronic cancer pain

It is cheap and low potency

Ongoing research being done on it.

How to perform an opioid rotation

◦ Without methadone

◦ To methadone

LA opioids dosed Q12H or QD

CHOMT

Codiene

Hydro

Oxycodone

Morphine

Tramadol

What should not be titillated with in opioids

LA opioids

kadian is dosed

Every 24 hours

More addicting