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PAIN CONTROL IN ADVANCED CANCER

PAIN CONTROL IN ADVANCED CANCER. Katharine House Hospice. PAIN. ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage Is always subjective Is what the patient says it is ¾ of patients experience pain, which means that ¼ don’t. Total pain.

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PAIN CONTROL IN ADVANCED CANCER

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  1. PAIN CONTROL IN ADVANCED CANCER Katharine House Hospice

  2. PAIN • ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage • Is always subjective • Is what the patient says it is • ¾ of patients experience pain, which means that ¼ don’t

  3. Total pain • PHYSICAL • SOCIAL • SPIRITUAL • PSYCHOLOGICAL

  4. PHYSICAL PAIN • NOCICEPTIVE • – somatic – well localised, eg bone metastases • - visceral – often poorly localised, eg liver capsule pain • NEUROPATHIC • - caused by nerve damage / destruction

  5. PAIN MANAGEMENT • Assessment • Explanation • Treatment • Re-assessment • ANALGESICS • - by the mouth, by the clock, and by the ladder

  6. WHO ANALGESIC LADDER • STEP ONE – non-opioid +/- adjuvants

  7. WHO ANALGESIC LADDER • STEP ONE – non-opioid +/- adjuvants • STEP TWO – weak opioid +/- non-opioid +/- adjuvants

  8. WHO ANALGESIC LADDER • STEP ONE – non-opioid +/- adjuvants • STEP TWO – weak opioid +/- non-opioid +/- adjuvants • STEP THREE – strong opioid + non-opioid +/- adjuvants

  9. Cox 2 inhibitors • No effect on platelet aggregation, so no substitute for asprin • Equally effective on pain as NSAIDs • Half the risk of perforations, ulcers and bleeds than with NSAIDs • trials only 12months long • Caution needed in renal failure • Cost comparison per month • rofecoxib 25mg od = £21.58 • diclofenac 75mg bd = £13.00

  10. Tramadol • Synthetic opioid 1/5 as potent as morphine • 200mg tramadol =40mg morphine daily • Similar action on nerves to amitriptyline • Less constipation than morphine • Lowers seizure threshold (so caution with SSRI’s and tricyclics) • Usual maximum dose is 400mg daily • Available as 50mg (quick release) or as slow release tabs

  11. MORPHINE • NOT the panacea for all pain. Not all pain is morphine responsive. • ALWAYS prescribe laxative with morphine • Lower doses in elderly / frail, and those with hepatic or renal impairment • Do not cut tablets open. However, capsule contents can be sprinkled in drink or food

  12. STARTING MORPHINE • - consider previous analgesia • - start with a regular 4 hourly dose, plus hourly prn dose • Convert to m/r morphine when the daily dose requirement is established • Prescribe an hourly prn dose – 1/6 of the total daily dose • Review regularly – increase dose as necessary, usually by 30-50%

  13. STARTING MORPHINE 2 • When changing to s/c morphine, divide dose by 2. • When changing to s/c diamorphine, divide dose by 3

  14. Opioid Switching • = substituting one strong opioid with another in order to achieve better balance between analgesia & side effects • 20-30% patients will not tolerate morphine • Indications: • Pain controlled but intolerable SE • Pain inadequately controlled but SE prevent increase in analgesic dose

  15. Fentanyl • Same action as morphine • Not useful for unstable pain (onset of action 12-18hrs) • Not useful for opioid naive patients (starting dose equivalent to 15mg MST bd) • Useful for patients on morphine whose dose is limited by side effects • use morphine for breakthrough pain

  16. New Fentanyl preparations for 2009 Fentanyl for breakthrough pain Abstral – sublingual muco-adhesive tablet Effentora – buccal tablet Instanyl – nasal spray Taifun – dry powder spray Staccatto – inhaler AeroLEF - inhaler

  17. Oxfordshire PCT • Do not expect any prescribing in primary care. • Guidance in conjunction with PC consultants. • Bioavailability issues between new fentanyl products and Actiq lozenge. • Traffic light as black (no primary care prescribing) for now - but with a plan to review this traffic light status once some joint guidance has been produced

  18. Buprenorphine (Temgesic) • Similar action to morphine • Similar side effects to morphine • Peak effect 3hrs, acts for 6-8hrs • Usual max dose = 400mcg 8hrly • equivalent to MST 40mg bd • At high doses, buprenorphine and morphine can be antagonistic • Give s/l, effect reduced by swallowing tablet

  19. Oxycodone Similar titration to morphine (oxynorm IR/oxycontin MR) More expensive then morphine and similar side effect profile. -?less delirium, sedation -?more constipation “Safe” in mild renal failure

  20. Opioid Toxicity Drowsiness, confusion, hallucinations, myoclonic jerks Respiratory depression Constricted pupils are NOT reliable or useful sign in palliative care patients on long-term opioids. NB multiple causes

  21. Neuropathic pain • Results from damage to, or dysfunction in, the nervous system and results in excess firing of nerve cells that are insufficiently controlled by inhibitory circuits • Pain in an area of abnormal or absent sensation • Can arise centrally or peripherally • Causes • cancer - nerve infiltration/compression, paraneoplastic • treatment - radiotherapy, chemotherapy, surgery • other conditions - post herpetic/V neuralgia, ischaemia, infection

  22. Clinical features • Burning, stinging, stabbing, shooting, electric-shock like, numbness, pins and needles, weakness in a nerve distribution • Allodynia - pain due to a stimulus which is not normally painful (e.g. stroking the skin) • Hyperalgesia - increased pain due to a stimulus which is normally painful (e.g. heat)

  23. Opioids Steroids Antidepressants Anticonvulsants Systemic local anaesthetics Ketamine TENS Topical agents Epidural Nerve blocks and neurosurgery Management of neuropathic pain

  24. Opioids • Morphine does have some effect on neuropathic pain • Methadone said to have additional NMDA antagonist activity • Tramadol said to have additional action of inhibiting monoamine reuptake

  25. Steroids • May work where extrinsic nerve compression by oedematous tumour is the cause of the neuropathic pain • May also work centrally on the cerebral cortex

  26. Antidepressants • Modulate pain signalling in the spinal cord • Older, less selective drugs (e.g. amitriptyline) work better than newer ones (e.g.paroxetine) • Pain relief cf antidepressant action • clinical response is quicker (1-7 days) • at lower dose (25-75mg nocte) • distinct from any effect on mood • NNT for post herpetic neuralgia 2.1 (1.7-3.0)

  27. Anticonvulsants • Stabilise neurones to prevent spontaneous discharge • Better documented evidence for gabapentin than any others BUT more expensive • Anticonvulsants vs antidepressants • few differences in efficacy and harm • incorrect that pain type predictive of response • NNT for postherpetic neuralgia 2.9(2.4-3.7)

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