Unit 11 Palliative Care Part 1: Pain Management

1. Unit 11 Palliative Care Part 1: Pain Management

2. Learning Objectives • Discuss the approach to relief of symptoms during the course of HIV infection • Describe the stepped approach to pain control and the use of analgesics Training on Clinical Care of HIV, AIDS and Opportunistic Infections

3. WHO Definition of Palliative Care • An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illnesses, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems—physical, psychological and spiritual (WHO, 2002) Training on Clinical Care of HIV, AIDS and Opportunistic Infections

4. Definition of Pain • An unpleasant sensory and emotional experience often associated with actual or potential tissue damage or described in terms of such damage. Adapted from international Association for the Study of Pain Training on Clinical Care of HIV, AIDS and Opportunistic Infections

5. Types of Pain • Nociceptive • Related to tissue injury or tissue stress • Neuropathic • Produced by nerves themselves • Intestinal Colic • Nociceptive, but worsened by opioids • Bone pain • May not respond to opioids Training on Clinical Care of HIV, AIDS and Opportunistic Infections

6. Pain as a Symptom of a Treatable Condition • Headache • Chest pain • Pharyngeal or retrosternal pain • Abdominal pain • Skin pain • Leg pain (neuropathy) • Generalised pain Training on Clinical Care of HIV, AIDS and Opportunistic Infections

7. Causes of Headache • Tension headache • Febrile illness • Malaria • Sinusitis • With focal abnormalities • Brain mass lesion like toxoplasmosis or tuberculoma • Acute Meningitis • Pneumococcus, Meningococcus • Chronic Meningitis • Cryptococcus and TB Training on Clinical Care of HIV, AIDS and Opportunistic Infections

8. Causes of Chest Pain • With cough or dyspnea • Pneumonia • Tuberculosis • Substernal pain not associated with swallowing • Mediastinal adenopathy or disease • TB, KS • Pericarditis • TB • Pain on swallowing • See retrosternal pain Training on Clinical Care of HIV, AIDS and Opportunistic Infections

9. Pharyngeal or Retrosternal Pain • Oropharyngeal • Tonsillitis/pharyngitis • Oral candidiasis • Herpes simplex • Aphthous ulcers • Kaposi’s Sarcoma • Gingivitis • Oesophageal • Acid reflux • Candidiasis • CMV or HSV • Aphthous ulcers • Kaposi’s Sarcoma Training on Clinical Care of HIV, AIDS and Opportunistic Infections

10. Abdominal Pain • Upper GI tract • Dyspepsia • Gastric or peptic ulcer disease • Enterocolitis/Diarrhea • Intestinal parasites • Bacterial dysentery • Clostridium difficile • TB, MOTT and CMV • Biliary Tract Disease • Opportunistic agents of enterocolitis • Abdominal masses • Peritonitis (TB) • Abscess • KS and lymphoma Training on Clinical Care of HIV, AIDS and Opportunistic Infections

11. Skin Pain • Herpes (Varicella) Zoster • Post-herpetic neuralgia • Skin infections • Impetigo and pyoderma • Folliculitis • Cellulitis Training on Clinical Care of HIV, AIDS and Opportunistic Infections

12. Leg pain • Neuropathy • HIV • Medications • d4T, ddI • INH • Vitamin deficiency • Post-Herpetic neuralgia • Diabetes • Poor circulation • Localized infections • Venous thrombosis Training on Clinical Care of HIV, AIDS and Opportunistic Infections

13. Generalised Pain • Fever • Bed-ridden status • Rheumatism • Non-specific etiology Training on Clinical Care of HIV, AIDS and Opportunistic Infections

14. Specific Treatment Symptom Relief Evolution of the illness Death Initial Diagnosis Passage of time Relationship Between Specific Treatment and Symptom Relief Training on Clinical Care of HIV, AIDS and Opportunistic Infections

15. Stepped Approach to Analgesic Therapy Severe Pain Strong opioids Moderate Pain Weak opioids Mild Pain Non-narcotic Training on Clinical Care of HIV, AIDS and Opportunistic Infections

16. Stepped Approach to Analgesic Therapy Training on Clinical Care of HIV, AIDS and Opportunistic Infections

17. Stepped Approach to Analgesic Therapy • For moderate to severe pain, can combine a non-narcotic (aspirin, paracetemol) with an opioid • Never combine a weak opioid (codeine) with a strong opioid (morphine) • Morphine is underutilized, resulting in unnecessary suffering of dying patients Training on Clinical Care of HIV, AIDS and Opportunistic Infections

18. Morphine Use in Namibia • Simplest formulation: MIST morphine • 15 mg/10 ml solution • N$1 per liter • Schedule 1 • Pharmacists or PMOs need to mix this • Pharmacists’ assistants cannot legally mix it (morphine powder schedule 7) • Once mixed, pharmacists’ assistants may dispense • Most potent formulation • 100 mg/5 ml solution • Schedule 7 • Most restricted • Under control of PMO / Medical Superintendent / Pharmacist Training on Clinical Care of HIV, AIDS and Opportunistic Infections

19. Morphine Use in Namibia (2) • Use the schedule 1 solution • 15 mg/10 ml • No maximum dose of MS, titrate to effect and tolerance • Always prescribe a laxative • Bisacodyl is effective • Extremely effective but underused in Namibia • More advocacy is needed to promote morphine use as part of palliative care Training on Clinical Care of HIV, AIDS and Opportunistic Infections

20. Adjuvant Pain Medications *not included in the Namibian Guidelines Training on Clinical Care of HIV, AIDS and Opportunistic Infections

21. Adjuvant Pain Medications Training on Clinical Care of HIV, AIDS and Opportunistic Infections

22. Adjuvant Pain Medications Training on Clinical Care of HIV, AIDS and Opportunistic Infections

23. Adjuvant Pain Medications Training on Clinical Care of HIV, AIDS and Opportunistic Infections

24. Adjuvant Pain Medications Training on Clinical Care of HIV, AIDS and Opportunistic Infections

25. Key Points • Relief of pain and other symptoms is part of care throughout the course of HIV disease • Specific treatment of illnesses and symptom relief improve the quality of life • In persons near the end of life, relief of symptoms is the main focus of care Training on Clinical Care of HIV, AIDS and Opportunistic Infections