Palliative Care: Pain and symptom management

1. Palliative Care: Pain and symptom management Carol May RN, MSN, MBA, CHPPN Supportive care program Children’s hospital of Pittsburgh of upmc

2. Pain Defined Pain is a subjective response Pain in childhood can be acute or chronic Children's pain is influenced by many factors

3. Populations at risk Chronic conditions Trauma/Injury Neonates/Infants Neurological Impairment Non-English speaking Cultural, gender stereotyping Hx substance abuse

4. Barriers to Pain Relief Healthcare professionals Healthcare system Related to parents/children

5. Myths Respiratory depression Addiction ‘Running out’ of pain meds Presence of pain indicates worsening of disease and approaching death

6. Facts About Childhood Pain Opioid addictions are rare Repeated exposure leads to increased anxiety and perception of pain Studies have shown that children as young as 3 years old can use pain scales Carter et al., 2004; Goldman et al., 2006; Hockenberry & Wilson, 2006; Schecter, 2003

7. Myths Related to Neonatal/Infant Pain Incapable of feeling pain Immature nervous system Incomplete myelinization No memory Objective assessment impossible Neonates cannot communicate pain Analgesics unsafe

8. Facts About Neonatal/Infant Pain Pain perception occurs early in life Neonates exhibit physiologic and behavioral cues

9. Impact of Pain • Research asked ‘What is it like to have a child with pain?’ • Unendurable • Helplessness • Sense of total commitment • Feels pain physically • Unprepared/unknowledgeable • Horrible/frightening • No pain in heaven • Wish for death Ferrell et al., 1994a & 1994b

10. Special Populations • Neurocognitive Impairment • Pain Experience • Pain Indicators • Effect of Uncontrolled Pain • Assessment • Knowing Child • Recognizing Patterns • Intersubjective process with HCP

11. Types of Pain Nociceptive Pain (normal processing of pain) Somatic Bone, joints, connective tissue Achy, throbbing Well localized Visceral Organs, soft tissue Aching, cramping Localized, diffuse Neuropathic Pain (abnormal processing of pain) Centrally mediated Deafferentation pain Sympathetic pain Peripherally mediated Polyneuropathies Mononeuropathies Sharp, shooting, electric Usually requires adjuvant medications

12. Tolerance  effect of a medication over time, requiring  dose to achieve same level of efficacy Should consider differential diagnosis Tolerance ≠ addiction Easily managed by dose orinterval between dosing Should not withhold opioid

13. Physiological Dependence Development of withdrawal syndrome after: Abrupt discontinuation of therapy Substantial dose reduction Administration of antagonist medication (naloxone)

14. Psychological Dependence (Addiction) Pattern of compulsive drug use characterized by continued craving for an opioid and the need to use the opioid for effects other than pain relief Three distinguishing characteristics Continued cravings with/without pain Illegal and anti-social behavior in order to obtain the drug Chronic, relapsing condition APS, 2003

15. Analgesics NSAIDs Cyclooxygenase inhibition leads to interference with production of PGs (Cox-2) Decreased PG’s also responsible for gastric SE’s (Cox-1) Cox-2 inhibitors do not inhibit Cox-1, thereby limiting gastric SE’s Can be used in mild, moderate, acute or chronic, pain alone Use in severe pain in combination with opioid + adjuvant Dosing PRN or ATC depending on source of pain Acetaminophen/NSAIDs • Acetaminophen • Little is known about mechanism of analgesia centrally mediated • Useful for mild pain, little anti-inflammatory action

16. Analgesics • Management of NSAID Side Effects • Primary SE is gastric irritation, heart burn • Serious SE is ulceration and bleeding • Use gastroprotective for prolonged use • Effect on platelet aggregation – short acting, reversible • Renal effects – rare, insufficiency and nephrotoxicity can occur with prolonged high doses

17. Analgesics Combination Analgesics (weak opioids) Codeine Use in mild pain only, limited use in severe pain Maximum recommended dose (60mg) produces analgesia equal to 600mg aspirin Combination product with acetaminophen Hydrocodone Only available in combination with acetaminophen, aspirin, or ibuprophen Not appropriate for moderate to severe pain

18. Analgesics Opioids Morphine as gold standard Variety of routes, formulations Large body of research Used for moderate to severe/intractable pain Fentanyl Used in anesthesia, procedural sedation Acute moderate to severe pain Patch has found use in some cancer and chronic non-malignant pain

19. Analgesics Opioids Hydromorphone More potent than morphine Available in high-potency formulations Methadone Gaining favor as analgesic in chronic pain Long half-life therefore longer time to steady state Not useful in breakthrough pain

20. Adjuvants Co-analgesics - medications that are used in combination with opioids to enhance analgesia or treat specific types of pain Antidepressants - amitriptyline, nortriptyline Anticonvulsants – gabapentin, tegretol Anesthetics - lidocaine, ketamine, propofol Corticosteroids – dexamethasone Anxiolytics - lorazapam, diazapam, midazolam Barbiturates - phenobarbitol, pentobarbitol

21. Analgesic Side Effects Constipation – Tolerance DOES NOT occur Miralax, senna and ducosate sodium, ducosate sodium, bisacodyl, mag citrate, lactulose Sedation – Tolerance w/in a few days Dextroamphetamine, methylphenidate, caffeine

22. Analgesic Side Effects (cont.) Urinary retention – oxybutynin Nausea/Vomiting – zofran, Ativan, benadryl Pruritus - diphenhydramine, hydroxyzine, narcan

23. Non-Pharmacological Pain Management Visualization/Guided Imagery Deep breathing/Relaxation Massage Heat Positioning Physical Therapy Hydrotherapy Consult Child Life, Social Work, Rehab Med for assistance

24. Why are we seeing more sympotms • Children are living longer with complex chronic medical conditions. • Multiple acute and chronic health crises create significant challenges for the child and family.

25. How can we as a team help the family • Family shapes types of interventions • Illness experience • QOL and sources of suffering as defined by the family • Goals of care • Curative/restorative • Life prolongation • Comfort

26. Symptoms and Suffering Determine priority symptoms for the child Symptoms create suffering and distress Interdisciplinary care Are we all talking together

27. Neurological • Autonomic Dysregulation • “storming” • Dystonias • Restlessness/Agitation • Seizure

28. Dystonia/Spasticity • Definitions • Populations • Complications • Management

29. Restlessness/Agitation • Definition • Causes • Assessment

30. Treatment • Provide routine, comfort and support • Decrease stimulation • Pharmacologic • Non-pharmacologic • Relaxation • Massage

31. Seizures • Overview • Causes • Presentation • Treatment

32. Dyspnea • Distressing shortness of breath • Breathlessness • Associated diseases

33. Treatment of Dyspnea • Non-pharmacologic • Oxygen • Energy conservation • Fans, elevation • Counseling • Other

34. Terminal Respirations • Characteristics • Causes • Assessment • Treatment

35. Issues Related to Fluids/ Nutrition • Personal/ethical dilemmas • No different then withholding artificial ventilation • Parental support

36. Causes of Constipation • Disease related (e.g. obstruction, hypercalcemia, neurolgic, inactivity) • Treatment related (e.g. opioids, other meds)

37. Causes of Nausea and Vomiting • Gastrointestinal causes • Metabolic Causes • CNS causes

38. Pharmacologic Treatment of Nausea and Vomiting • Anticholinergics • Antihistamines • Steroids • Prokinetic agents • Other

39. Non-Drug Treatment of Nausea and Vomiting • Distraction • Dietary • Small/slow feeding • Invasive therapies

40. Fatigue • Subjective, multidimensional experience of exhaustion • Commonly associated with many diseases • Impacts all dimensions of quality of life

41. Causes of Anxiety • Medications and substances • Uncertainty

42. Treatment of Anxiety • Medications • Empathetic listening • Assurance and support • Maximize symptom management • Relaxation/imagery

43. What symptoms? • What have you seen that you have questioned the treatment of??