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Pain and Symptom Management

Pain and Symptom Management. Fran MacIvor Locum Consultant, Palliative Medicine. Pain basics, and a little bit about nausea and constipation. Important things from today…. Pain – its not all the same Importance of details How to prescribe strong analgesia. Types of pain. Visceral pain.

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Pain and Symptom Management

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  1. Pain and Symptom Management Fran MacIvor Locum Consultant, Palliative Medicine

  2. Pain basics, and a little bit about nausea and constipation

  3. Important things from today…. Pain – its not all the same Importance of details How to prescribe strong analgesia

  4. Types of pain Visceral pain Nerve TOTAL PAIN Musculo-skeletal (somatic) Bone pain

  5. Assessment • Nature • Pattern (Breakthrough? End of dose? Incident?) • Severity / intensity (see scales*) • Effect of current analgesia • What do they think is the cause?

  6. Visual pain scales

  7. The WHO ladder Sorts out 80 – 90% of pain if used properly Analgesia – the basics

  8. Case • Mr. B, 60 y.o. man • Lung cancer • Invasion of ribs on right • Tramadol 100mg QDS, paracetamol 1g QDS • Still in pain….

  9. Initiating Step 3 - Opiates Initiating Opiates

  10. Introducing opiates – a safe start… • Start with simple morphine unless there is a reason not to • Use prn doses of short acting morphine (oramorph) initially to assess • a) effectiveness • b) side effects? • Calculate total dose of oramorph used over previous 24 hours • Divide total in two and give as long acting MST BD

  11. Give 1/6th of total 24 hour dose, as required for breakthrough, up to once every hour if needed • Next day, look again at total breakthrough used and titrate up long-acting MST appropriately • Remember the breakthrough dose may need to be increased too • REMEMBER S/C MORPHINE IS 2X AS STRONG AS ORAL ie. HALVE THE ORAL DOSE

  12. Reasons for caution…… • Signs of opiate toxicity • Drowsy • Confused • Myoclonic jerks • Hallucinations (visual peripheral especially) • Nausea • Pupils • Respiratory depression

  13. Case • Mrs G. • 90 year old • Pathological fracture of hip • Dementia, NH resident • Communication difficult • What issues might there be in providing adequate pain relief?

  14. Examples of adjuvants • Anticonvulsants • Antidepressants • Steroids • Muscle relaxants • Bisphosphonates • Chemo / radiotherapy • Surgery

  15. Opiate switching • Alternatives to morphine; • Oxycodone • Hydromorphone • Fentanyl / Alfentanil • Diamorphine • Methadone

  16. Nausea and Vomiting • Common causes are common! • Drugs • Treatments • Tumour type and position

  17. Constipation • Poor oral intake does not mean no poo • Immobility • Drugs • Disruption of habit • Altered gut function • Always prescribe a laxative with opiates

  18. Factors associated with worse experience of nausea/vomiting • Tumour type • Female • Younger than 50 • History of travel sickness • Anxious personality

  19. Causes of nausea and vomiting

  20. Put right what you can… • Rehydrate • Treat blood abnormalities (Ca, Urea etc.) • Stop offending drugs • GET BOWELS MOVING

  21. Drugs (v. simplified)

  22. Help with symptoms • HPCT (Tay-UHB.palliative@nhs.net) • www.palliativecareguidelines.scot.nhs.uk • Palliativedrugs.com

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