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Analgesic Trade Secrets. Dr Hannah Gunn Consultant in Palliative Medicine Northumbria Healthcare & Marie Curie Hospice Newcastle. Session Outline. Defining pain Types of pain Noceceptive Neuropathic Total WHO Analgesic Ladder Adjuvants Case histories. Defining Pain. What is pain?.
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Analgesic Trade Secrets Dr Hannah Gunn Consultant in Palliative Medicine Northumbria Healthcare & Marie Curie Hospice Newcastle
Session Outline • Defining pain • Types of pain • Noceceptive • Neuropathic • Total • WHO Analgesic Ladder • Adjuvants • Case histories
What is pain? • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage • International Association for the Study of Pain (IASP) 1986
What is pain? • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage • International Association for the Study of Pain (IASP) 1986 • Pain is what the patient says hurts
Types of Pain • Nociceptive Pain • Neuropathic Pain
Types of Pain • Nociceptive Pain • Transmitted by undamaged nervous system • Opioid receptors involved • Impulse spinal cord higher centres • WHO analgesic ladder • Neuropathic Pain • Transmitted by damaged nervous system • Partial opioid sensitive • Associated with hyperalgesia and allodynia • WHO analgesic ladder • Adjuvants
Pain Management Strategy • Modify pathological process • Surgery • Radiotherapy • Chemotherapy • Choose an analgesic • WHO analgesic ladder • Adjuvants • Side effects • Non-drug management of pain • Address all the domains of total pain • Heat pads, TENS • Lifestyle modification • Home equipment • Walking aides • Care package
Choice of drug based on severity of pain NOT on stage of disease
When is an analgesic not an analgesic? Methadone Ketamine Anti-spasmodic When it’s an adjuvant! Steroid Anti-epileptic Bisphosphonate Muscle relaxants Anti-depressant
AdjuvantDrugs AdjuvantDrugs Choice of drug based on severity of pain NOT on stage of disease
Case 1 • Joan, 63 year old woman • Diagnosed with left breast cancer 2 years ago • Mastectomy • Radiotherapy and chemotherapy • Ongoing hormone therapy • Presents to GP with RUQ pain, worse on inspiration, ‘like I’ve pulled a muscle’ • Some vomiting, especially later in day, large volumes, hiccoughs and belching
Liver Capsule Pain • Aetiology • Liver metastases • Presentation • RUQ pain • Stretch quality • Can vary with respiration • Management • Dexamethasone 8-16mg mane with PPi cover
Case 2 • Brian, 74 year old man • 8 year history of prostate cancer • Admitted with severe lower back pain, increasing for last few weeks, now unable to walk due to pain
Bone Pain Paracetamol and NSAID and morphine • Aetiology • Bone infiltration • Pathological fractures • Presentation • Severe pain • Associated with site of metastases • Management • WHO analgesic ladder • Adjuvant analgesics • Dexamethasome 8-16mg mane with PPi cover • Bisphosphonate infusion • Gabapentin or amitriptyline
Pain is what the patient says hurts • WHO analgesic ladder • Adjuvants • Review, review, review
Pain is what the patient says hurts • WHO analgesic ladder • Adjuvants • Review, review, review • Ask your friendly neighbourhood palliative care team!
Thank You! HannahGunn@nhs.net