Pain management in palliative care 3

1. Pain management in palliative care 3 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

2. Outline Review of days 1 & 2 Treatment in children Non-pharmacological treatment Treatment in HIV/AIDS Special situations MKF 2016

3. Overview of palliative care Total Care Continuum of Care

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

5. 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

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

7. Overview of pain management ECG of pain Mechanism of pain Types of pain WHO analgesic ladder

8. Pain Assessment . . . • Symptom Assessment – PQRST strategy • What Provokes or Palliates the pain? • What is the Quality of the pain? • What Regions are involved, and does it Radiate? • What is the Severity of the pain (0 – 10 scale)? • What is the Timing of the pain? • Detailed pain medication and treatment history • Prior opioid (prescription or not) and substance use MKF 2016

9. Pain Terminology MKF 2016

10. WHO Analgesic Ladder: adults Step 3 Strong opioid Step 2 Weak opioid Step up if pain persists or increases Severe pain Step up if pain persists or increases Step 1Non-opioid Moderate pain +/- non-opioid+/- adjuvant +/- non-opioid+/- adjuvant Mild pain +/- adjuvant Consider prophylactic laxatives to avoid constipation Non-opioidsibuprofen or other NSAID, paracetamol (acetaminophen), or aspirin Weak opioids codeine, tramadol, or low-dose morphine Strong opioids morphine, fentanyl, oxycodone, hydromorphone, buprenorphine Adjuvants antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid Combining an opioid and non-opioid is effective, but do not combine drugs of the same class. Time doses based on drug half-life (“dose by the clock”); do not wait for pain to recur 10 Adapted by Treat the Pain from World Health Organization http://www.who.int/cancer/palliative/painladder/en/ (accessed 7 November 2013)

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12. Breakthrough, emergency, and incident 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

13. Breakthrough pain • Breakthrough pain: a sudden, temporary flare of severe pain that occurs on a background of otherwise controlled pain • May be more common during first three days of treatment as morphine dose is titrated from starting dose to effective dose MKF 2016

14. Diagnostic criteria Stable analgesic regimen in the previous 48 hours Presence of controlled background pain in the previous 24 hours (i.e. average pain score <5 out of 10) Temporary flare of severe or excruciating pain in the previous 24 hours MKF 2016

15. Rescue dose • Rescue dose: a dose of immediate-release morphine that is the same as the dose given every 4 hours and can be given as often as required to treat breakthrough pain • Note these in the patient chart • Write orders that include rescue doses MKF 2016

16. Pain emergency The goal is to control pain (i.e. to get pain score below 5 out of 10) • If patient is in excruciating pain (pain score=9 or 10), it is considered a pain emergency • Administer rescue dose intravenously (IV) • Remember to convert oral dose to IV dose by dividing by 2-3 • Otherwise rescue doses can be oral • Wait for dose to take effect (10 minutes for IV and 30 minutes for oral) and then reassess • Repeat dose if pain score is 5 or higher MKF 2016

17. Incident pain and end-of-dose failure Types of pain that are similar to breakthrough pain Incident pain End-of-dose failure MKF 2016

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19. Side effects and toxicity of analgesics 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

20. Side effects • Step 1 drugs: • Acetaminophen • NSAIDS • Step 2 drugs: • Codeine, etc • Step 3 drugs MKF 2016

21. Step 3 analgesic: morphine • When used correctly, problems like dependency, addiction, tolerance, and respiratory depression are rare • Opioids are not toxic to any organ • No contraindications except history of allergic reactions (rare) MKF 2016

22. Step 3 analgesic: morphine Constipation is a very common side effect of all opioids and does not resolve spontaneously • Laxatives should be prescribed as prophylaxis unless patient has diarrhoea • Treat with a stimulant laxative • i.e. Bisacodyl 5mg at night, increasing to 15mg if needed MKF 2016

23. Step 3 analgesic: morphine Nausea and vomiting • Usually mild and resolves within one week • Anti-emetics (metoclopramide or haloperidol) can be given for the first few days of treatment • Metoclopromide 10mg every 8 hours or haloperidol 1.5mg once a day Itching • Less common • Treat with chlorpheniramine MKF 2016

24. Opioid toxicity • Toxic effects of opioids are rare when they are used in appropriate doses • Signs include • Drowsiness that does not improve • Confusion • Hallucinations • Myoclonus (abrupt spasms or muscle twitching) • Respiratory depression (slow breathing) • Pinpoint pupils MKF 2016

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26. Addiction and dependence 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.

27. Risk of addiction in medical use of opioids • According to the World Health Organization: • A systematic review of research papers concludes that only 0.43% of patients with no previous history of substance abuse treated with opioid analgesics to relieve pain abused their medication and only 0.05% developed dependence syndrome • Fishbain et al (2008): Among chronic pain patients with no history of opioid abuse/addiction, incidence of abuse/addiction is 0.19% MKF 2016

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29. Treatment in children 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

30. Objectives Review methods of assessing pain in children Discuss treatment options and dosing for children based on the age of the child and their level of pain

31. 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 Children’s Palliative Care in Africa, 2009

32. 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 Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for Palliative Care (2007)

33. 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 ICPCN (2009): Adapted from Merkel et al

34. 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.

35. 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.

36. WHO Analgesic Ladder: Pediatric Step 2 Strong opioid Step up if pain persists or increases Moderate or Severe pain Step 1Non-opioid +/- non-opioid+/- adjuvant Mild pain +/- adjuvant Consider prophylactic laxatives to avoid constipation Non-opioids Age>3 mos: ibuprofen or paracetamol (acetaminophen); Age<3 mos:paracetamol Strong opioids morphine (medicine of choice) or fentanyl, oxycodone, hydromorphone, buprenorphine Adjuvants antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid Combining an opioid and non-opioid is effective, but do not combine drugs of the same class. Time doses based on drug half-life (“dose by the clock”); do not wait for pain to recur 36 Ref: Adapted by Treat the Pain from World Health Organization http://www.who.int/cancer/palliative/painladder/en/ (accessed 7 November 2013)

37. WHO ladder: pediatric • Recently updated guidelines from the World Health Organization (WHO) recommend using a 2-step ladder which does not include the rung for weak opioids • Weak opioids are not recommended for use in children • Codeine • Safety and efficacy problems related to genetic variability that affects metabolism • Low analgesic effect in infants and young children • Tramadol • Data are lacking on safety and efficacy in children WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

38. Step 1: mild pain • Paracetamol and ibuprofen are the only medicines in this step • No other NSAIDs are recommended • Infants <3 months old • Only paracetamol is recommended • Children >3 months old • Paracetamol or ibuprofen can be used WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

39. Dosing of Step 1 analgesics WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

40. Step 2: moderate or severe pain “There is no other class of medicines than strong opioids that is effective in the treatment of moderate and severe pain. Therefore, strong opioids are an essential element in pain management.” World Health Organization WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

41. Step 2: moderate or severe pain • Morphine is the “medicine of choice” • Alternatives can be used if a child experiences intolerable side-effects • As with adults, there is no maximum dose for opioids • Titrate upward to find the dose that relieves pain with tolerable side-effects • Constipation is a common side effect, and all children taking opioids should also take a stimulant laxative and a stool softener WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

42. Starting dose for opioid-naïve neonates WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

43. Starting dose for opioid-naïve infants (1 mo-1 yr) WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

44. Starting dose for opioid-naïve infants (1 mo-1 yr) WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

45. Starting doses for opioid-naïve children (1-12 yrs) WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

46. Starting doses for opioid-naïve children (1-12 yrs) These opioids are more complex and should be started by an experienced provider WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

47. General principles • Dose at regular intervals • Medicines should always be given on a regular schedule and not “as needed”, except for rescue doses • Use the appropriate route of administration • Medicines should be given by the simplest, most effective, and least painful route • Oral is preferred • IV or subcutaneous, rectal, or transdermal are alternatives when oral is not feasible • IM is discouraged because it is painful • Adapt treatment to the individual child • Titrate to get to the correct dose WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

48. Side effects of opioids Opioids are generally well-tolerated Mild sedation for first 48 hours is normal while child catches up on sleep Constipation: treat with laxatives Pruritis: treat with topical treatments (calamine or hydrocortizone) or oral antihistamines Urinary retention: treat with carbachol or bethanechol; catheterization may be required Children’s Palliative Care in Africa, Amery (2009)

49. Co-analgesia in children • The WHO does not recommend corticosteroids or biphosphonates to treat pain in children • Neuropathic pain in children • Consult an expert • WHO guidance in this area is limited due to lack of evidence WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. WHO (2012)

50. Procedural pain management principles Avoid non-necessary procedures Prepare for the procedure Involve the child and family Encourage the parents to be helpful and supportive Carry out procedures in child-friendly area away from the bed Use non-pharmacological and pharmacological interventions to manage pain and anxiety After completing the procedure, congratulate the child and instill a sense of achievement Children’s Palliative Care in Africa, Amery (2009)