Pain Management in Palliative Care

1. Pain Management in Palliative Care Palliative Care Team MKF 2016

2. Outline Pre-test Introduction to palliative care Introduction to pain Mechanism of pain Pain assessment WHO analgesic ladder Equianalgesic dosing MKF 2016

3. Introduction to palliative care Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015 MKF 2016

4. MKF 2016

5. What is Palliative Care? WHO Definition Palliative care is an approach that improves the quality of life of patients and their familiesfacing the problems associated with life-threatening illness, through the prevention and relief of sufferingby means of early identification and impeccable assessment and treatment of pain and other problems physical, psychosocial and spiritual. MKF 2016

6. Dame Cicely Saunders Concept of Total Pain Total Pain MKF 2016

7. When does PC Start? MKF 2016

8. Traditional Model of Care Hospice Curative Care Presentation/Diagnosis Death MKF 2016

9. Palliative Care in the Continuum Diagnosis Death ILLNESS DEATH HEALTH Curative & Life Prolonging Care Palliative Care Symptom Management Life Closure EOL/ Dying Bereavement Prevention CURATIVE CARE HOSPICE CARE MKF 2016

10. MKF 2016

11. Introduction to pain Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

12. Objectives By the end of the session, learners should be able to: Define the term pain Name the common opioid analgesics Understand that the World Health Organization considers morphine to be an essential medicine Describe the disparity in access to morphine by country income level Give key advantages of morphine relative to other pain medicines Describe challenges that limit access to morphine Understand why pain treatment is important Name the simple treatment algorithm that relieves pain in 80-90% of people Challenge some common myths about pain treatment MKF 2016

13. Pain • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage • Pain is a subjective experience. The experience varies from person to person and from time to time • Pain is whatever the experiencing person says it is, existing wherever he says it does MKF 2016

14. Total pain: how patients experience pain PHYSICAL PSYCHOLOGICAL EMOTIONAL TOTAL PAIN SPIRITUAL • Patients experience pain on several levels and effective treatment requires a holistic assessment • This training program focuses on physical pain MKF 2016

15. Who suffers from pain? Pain is prevalent in almost all medical specialties including general practice, palliative care, oncology, internal medicine, haematology, and surgery Patients who are affected include people who have cancer, HIV, sickle-cell disease, those who have surgery or accidents, and potentially other patients Approximately 80% of people with advanced cancer and 50% of people with advanced HIV experience moderate or severe pain MKF 2016

16. Opioid analgesics for pain relief • Analgesics are medicines that relieve pain • Opioids are medicines that are derived from opium poppy plants or synthetic formulations that act in the same way • Weak opioids • Codeine • Tramadol • Dihydrocodeine • Strong opioids • Morphine • Fentanyl • Oxycodone • Hydrocodone • Buprenorphine • Methadone MKF 2016

17. World Health Organization Opioid analgesics, including morphine, are considered essential medicines by the World Health Organization Strong opioid analgesics are the only treatment for moderate or severe pain recommended in World Health Organization guidelines No suitable alternatives have been found MKF 2016

18. Disparity in access to opioids Opioids are on almost all national essential medicines lists, but access to them is severely limited in most low and middle-income countries, where 85% of the world’s population consumes just 7% of the medicinal opioids MKF 2016

19. Number of deaths with untreated pain (2012) Deaths with untreated pain • The lowest treatment coverage rates are: • South Asia: 9% • Sub-Saharan Africa: 20% MKF 2016

20. Access to morphine differs according to country income level Maximum coverage rate for deaths in pain from HIV or cancer based on national consumption of opioid analgesics: High-income countries: 100% Middle-income countries: 62% Low-income countries: 19% People in lower income countries are significantly less likely to get pain treatment than people in higher-income countries MKF 2016

21. Opioid analgesics for pain relief Opioids are the foundation of pain management for moderate or severe pain No organ toxicity, even at high doses and after prolonged use Side effects diminish over time Potential harmful side effects are avoidable when opioids are used correctly MKF 2016

22. Morphine advantages Most effective treatment for severe pain Safe (if used according to guidelines) Effective Plentiful Inexpensive Easy-to-use MKF 2016

23. Challenges that limit access to morphine Although morphine is inexpensivepeople lack access due to: Inadequate training or lack of knowledge of healthcare providers Cultural misperceptions about pain Lack of appropriate government policies or guidelines Legal and regulatory restrictions Weak procurement systems Disproportionate concern about diversion, addiction, and abuse Practices meant to prevent abuse of morphine that result in limited access for those in need of pain relief MKF 2016

24. Advantages of pain treatment In low-resource countries, pain is the most common indication for visiting a health care practitioner Pain treatment: Improves compliance to curative treatment Extends survival for some patients Improves quality of life Improves patient – physician relationship Reduces unnecessary prolonged admission MKF 2016

25. MKF 2016

26. Mechanisms of pain Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

27. Objectives for this module • Discuss the ways pain can be characterised • Duration • Mechanism • Origin • Situation MKF 2016

28. Characterisations of pain Pain can be described by its: Duration – acute or chronic Mechanism – nociceptive or neuropathic Origin – somatic or visceral Situation – incidental pain, breakthrough pain, procedural pain MKF 2016

29. Different mechanisms of pain Why are they important? Pathophysiology is different Presentation is different Management is different MKF 2016

30. Duration: acute vs. chronic pain Acute pain • Presentation: characterized by help-seeking behavior such as crying and moving about in a very obvious manner • Cause:definite injury or illness • Signs/symptoms: • Definite onsetwith limited and predictable duration • Clinicalsigns of sympathetic over-activity: tachycardia, pallor, hypertension, sweating, grimacing, crying, anxious, pupillary dilation • Example: trauma, surgery, or inflammation MKF 2016

31. Duration: acute vs. chronic pain Chronic pain • Presentation: Patients may not show signs of distress seen in acute pain • Cause: chronic pathological process • Under-treatment of acute pain can lead to changes in the central nervous system that result in chronic pain • Signs/symptoms: • Gradual or vague onset • Continues and may become progressively more severe • Patient may appear depressed and withdrawn • Usually no signs of sympathetic over-activity MKF 2016

32. Mechanism: nociceptive pain Nociceptive pain: caused when nerve receptors called nociceptors are irritated. Nociceptors exist both internally (visceral) and externally (somatic) Indicates that nerve pathways are intact MKF 2016

33. Nociceptive pain: somatic pain Somatic pain: stimulation of nociceptors in the skin, soft tissues, muscle, or bone Pain usually is in a particular location Aching, throbbing, or persistent pain Causes: bone or soft tissue infiltration MKF 2016

34. Nociceptive pain: visceral pain Visceral pain: stimulation of nociceptorsin internal organs and hollow viscera organs Pain is often not in a single location Described as pressure, cramping, or squeezing pain Causes: blockage, swelling, stretching, or inflammation of the organs from any cause MKF 2016

35. Mechanism: neuropathic pain Neuropathic pain: caused by damage to nerve pathways Described as burning, prickling, stinging, pins and needles, insects crawling under skin, numbness, hypersensitivity, shooting, or electric shock Causes: infiltration by cancer, HIV infection, or herpes zoster, drug-related peripheral neuropathy, central nervous system injury, or surgery MKF 2016

36. Situation Incident pain – occurs only in certain circumstances (e.g. after a particular movement) Breakthrough pain – a sudden, temporary flare of severe pain that occurs on a background of otherwise controlled pain Procedural pain – related to procedures or interventions MKF 2016

37. Assessment Jane has come to your clinic with pain she’s describing as constant shooting pain in her feet for the past four days. How would you classify her pain? A. Procedural pain B. Chronic, visceral pain C. Acute, neuropathic pain D. Acute, incident pain MKF 2016

38. Take home message Knowing the differences in the mechanisms of pain is important to adequately and appropriately treat the pain MKF 2016

39. MKF 2016

40. Pain Assessment Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

41. Objectives Explain how pain scales are used to measure pain Compare different scales Measure pain MKF 2016

42. Measuring pain Pain is subjective and two patients may report severity differently from each other Despite the fact that pain is specific to each person, patients can usually accurately and reproducibly indicate the severity of their symptom by using a scale Scales enhance the ability of patients to communicate the severity of their pain to health care professionals and the ability of clinicians to communicate among themselves Scales also allow the clinician to assess the effect of medications MKF 2016

43. Pain scales Scientifically validated pain scales: • Numeric Pain Rating Scale • Wong-Baker FACES Scale: for children who can talk • Observation-FLACC Scale: for children who can’t talk MKF 2016

44. Numeric pain rating scale Pain levels from 0-10 can be explained verbally to the patient using a scale in which 0 is no pain and 10 is the worst possible pain imaginable Patients are asked to rate their pain from 0 to 10 Record the pain level to make treatment decisions, follow-up, and compare between examinations MKF 2016

45. Three ways to assess pain in children • Ask the child: FACES scale • Ask the parent or caregiver • Ask about previous exposure to pain, verbal pain indicators, usual behavior or temperament • Observe the child: FLACC scale • The child is the best person to report their pain MKF 2016

46. Wong-Baker FACES scale Use in children who can talk (usually 3 years and older) Explain to the child that each face is for a person who feels happy because he has no pain, or a little sad because he has a little pain, or very sad because he has a lot of pain Ask the child to pick one face that best describes his or her current pain intensity Record the number of the pain level that the child reports to make treatment decisions, follow-up, and compare between examinations MKF 2016

47. FLACC scale • Use in children less than 3 years of age or older children who can’t talk • Use it like an APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score, arriving at a score out of 10 MKF 2016

48. FLACC scale • Score each of the five categories (0-2) • Add the five scores together to get the total (out of 10) • The total score can be related to pain intensity MKF 2016

49. Practice using FLACC scale Samuel is 18 months old. You observe that he is withdrawn, kicking his legs, and squirming. His is constantly crying or screaming, but is calmed down by breastfeeding. MKF 2016

50. Detailed pain assessments • Detailed pain assessments are useful for treating patients with pain • Tools like the PQRST and body charts provide detailed information on location and type of pain as well as quality and response to treatment MKF 2016