Pain

1. Pain

2. Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage Twycross 1997 Because pain is subjective, a patient�s self report is the gold standard for assessment Portenoy & Lesage 1999 Pain can be physical, psychological, emotional or spiritual.

3. Pain and Cancer Pain and cancer do not always go together � of patients experience pain � of patient do not experience pain Of those patients that have pain 1/3 has a single pain 1/3 has two pains 1/3 has three or more pains 15% of those patients with pain will have pain due to another cause

4. Pain Pain affects all aspects of a persons life Psychologically -anger, anxiety, fear, powerlessness Spiritually �distress, self image Physically -bathing, grooming, toileting, sexual dysfunction, mobility, sleep disturbance, fatigue Socially �isolation, loss of role Total pain

5. Pain Classification Cancer pain can be: Acute � associated with autonomic symptoms eg. sweating, tachycardia. Chronic � associated with sleep disturbance, anorexia, lethargy, personality change Nociceptive � caused by invasion or pressure &/or destruction on local structures Neuropathic � caused by pressure on or des- truction of nervous system structures, or radiation of pain along nerves

6. Pain Pain increased Discomfort Insomnia Anxiety Fear Anger Sadness Depression Boredom Mental Isolation Social Abandonment Pain decreased Relief of symptoms Sleep Understanding Companionship Creative activity Relaxation Reduction in anxiety Elevation in mood

7. Pain Pain directly caused by the cancer & metastatic spread Soft tissue infiltration Bone invasion Nerve pain Visceral pain Pain caused by cancer treatment Surgery Radiotherapy Chemotherapy Pain associated with progressing malignant illness Pressure areas Infection Musculoskeletal Dyspepsia /Colic Incidental pain unrelated to the cancer Osteoarthritis Angina, Peripheral Vascular disease

8. Pain management � 5 steps Step 1 Assess Fact finding Observation History taking Physical Step 2 Identify problems Defining the problem Making a diagnosis Making a problem list

9. Pain Assessment When did it start Where is it and does it go anywhere else What does it feel like Is it constant or does it come and go Does anything make it better or worse Are there any associated symptoms Is it limiting the patient activities What does the patient think it is due to What does the patient feel about the pain What analgesics have been tried and what effect did they have What are the patients expectations of treatment What are the patients fears What is the patient previous experience of pain and illness

10. Pain Step 3 Planning the intervention Action treatment & nursing care Goal setting Priority setting Identifying needs Assessment of the needs Step 4 Intervention Administering the medication Counselling Referral Co-ordinating services

11. Pain Step 5 Evaluation Evaluation of all the interventions Present response Not all pains are responsive to morphine How many breakthrough doses have been taken Goals Good night sleep No pain at rest No pain on movement

12. Pain management Communication/ information to reduce psychological impact of cancer Modification of the pathological process Radiation/ Surgery/ Chemo./ Hormone therapy Analgesia Non opioid Opioid Adjuvant Non Drug Method Heat pads Complementary therapies TENS Psychological Relaxation /therapies Interruption of pain pathways Nerve blocks Modification of way of life Avoiding painful activities Immobilisation of painful parts Collars/slings /ortho surgery Walking aids Wheelchair hoist

13. Who Three Step Analgesic ladder 3 Strong Opioid +/-Adjuvant 2 Weak opioid +/-Non opioid +/- Adjuvant 1 Non opioid +/-Adjuvant By the mouth* by the clock* by the ladder *for individual *attention to detail*use adjuvants

14. Pain management Step 1 Paracetamol Centrally acting synthetic non-opioid with analgesic and pyretic Inhibits CNS prostaglandin production Act within 15-30mins durations 4-6hrs Preparations liquid tablets capsules suppositories parenteral Dose 1 gram 6hourly No more than 8 tablets in 24 hours

15. Pain management Step 2 Codeine Antitussive & antidiarroeheal 1/10- 1/12 as strong as morphine Dosage 30-60mg No more constipating than morphine Side effect also similar � constipation, nausea, dry mouth, dizziness Tramadol Hydrochloride Dose 50-100mg every 4 hours Side effects similar to Morphine 50mg 100mg IR/ 100mg SR/ 150mg 24hrly prep/ 50mg caps Sachets

16. Pain management Step 3 Morphine preparations Immediate release Oramorph solution 10mg/5ml 20mg/1mg Sevredol tablets 10mg, 20mg, 50mg Injection 10mg, 15mg, 20mg and 30mg/ml Modified release MST Continus tabs (12hrly) 5mg 10mg 15mg 30mg 60mg 100mg 200mg MST Continus susp (12hrly) 20mg 30mg 60mg 100mg 200mg Zomorph caps (12hrly) 10mg 30mg 60mg 100mg 200mg

17. Pain management Step 3 Strong Opioids Oxycodone Oxynorm capsules and liquid IR, 5mg 10mg, 20mg 5mg/5mL 10mg/1mL Oxycontin 12hrly SR tablet 5mg 10mg 20mg 40mg 80mg Oxynorm for injections 10mg/ml Fentanyl Transdermal patches 12, 25, 50, 75, 100 mcg/hr Abstral, Effentora Methadone Tabs. 5mg. Oral soln. 1mg/ml, 10mg/ml. Injn. 10mg/ml. BD dose with 3hrly lockout for prns

18. Pain management Step 3 Strong opioids Diamorphine Hydrochloride Not recommended orally Injection 5mg,10mg,30mg,100mg Dilutes in a small volume, mixes well with other drugs Buprenorphine SLTablets 200mcg Bu Trans 7 days 5, 10, 20 Transtec 3 days 35, 52.5, 70

19. Pain management Side effects of analgesia *drowsiness *constipation *confusion *sweating *respiratory depression *hypotension *dry mouth *pruritis *nausea and vomiting * decreased libido It is prudent to prescribe a laxative and an anti-emetic prn.

20. Pain management Adjuvant analgesia Corticosteriods eg Dexamethasone Antidepressants eg Amitriptyline, Nortriptyline Anticonvulsants eg Gabapentin, Pregabalin, Carbamazepine Anti-spasmodics eg Buscopan Muscle relaxants eg Diazepam, Clonazepam Bisphosphonates eg Zoledronate NSAIDs eg Ibuprofen, Diclofenac

21. Pain management NEUROPATHIC PAIN 30-40% of cancer related pain can be difficult to control Opioids NSAIDs Radiotherapy Steroids e.g Dexamethasone Tricyclic antidepressants e.g Amitriptyline Anticonvulsant e.g Gabapentin, Carbamazepine Ketamine Methadone Spinal �epidural /intrathecal Nerve blocks

22. Is it working? If not, why not? Barriers to consider if pain control not achieved: Missed causes and influencing factors Poor patient understanding Incorrect dosing Side effects Patient compliance Patient concerns re. opioid use Spiritual or emotional distress

23. Addiction and Opioids Addiction and physical dependence are not the same thing Addiction � psychological dependence on the use of substances for their psychic effects � compulsive use despite harm Physical dependence � an expected physiological consequence of the extended use of opiates for pain � reducing the dose gradually can prevent withdrawal symptoms

24. Use of Naloxone A pure and potent opioid antagonist Has a high affinity for morphine receptor sites and reverses the effects of opioids by displacement Reverses opioid induced respiratory depression Use cautiously in palliative care pts. as it will reverse analgesic effects ________________