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Pain management in palliative care

WHO defines palliative care as ” the active , holistic care of patients with advanced , progressive illness. Management of pain and other symptoms and provision of psychological , social and spiritual support is paramount. the goal of palliative care (PalCa) is the achievement of the best quality of life for patients and their families “

 

The International Association for the Study of Pain ( IASP ) describes pain as ” an unpleasant sensory and emotional experience associated with either actual or potential tissue damage , or described in terms of such damage ” 

It can best be described as a multidimensional experience with sensory, cognitive and behavioral aspects.

 

Patients in need of palliative care include those who have chronic diseases as Cardiovascular disease , cancer , chronic respiratory diseases , AIDS and diabetes
( several other conditions may also require palliative care for e,g end stage renal disease and other end stage diseases ) It is now known that non-cancer patients suffer similar levels of pain to those found in patients with malignant disease Cancer pain is important as it has a severe impact on QoL & is associated with numerous psychological responses Pain along with difficulty of breathing are the two most frequent and serious symptoms experienced by patients in need of palliative care ( and fatigue ) A meta-analyses of 52 studies over 40 yrs reported that 64 % of patients with advanced cancer have pain It is estimated that about 1/3rd of people who are receiving cancer treatment and 2/3rd with advanced malignant disease experience pain Uncontrolled pain is a common reason for admission to secondary care in cancer patients WHO reports that worldwide only about 14 % of people who need PalCa currently receive it.

 

Barriers in treatment -May be under-recognised and under-treated Patients list uncontrolled pain as a primary source of fear for EOL care Barriers in provision of adequate pain relief may be due to
○ lack of national policy / systems /limited access to opioids / insurance
○ denial by patient and or family -thinking that pain or increasing pain is a sign of deterioration / progression or it is natural part of the illness
○ cultural and social beliefs about death and dying
○ misconceptions as PalCa is meant for cancer patients only or for last weeks of life
○ risk of addiction to opiates
○ health care professionals related causes – fear causing harm , lack of knowledge about analgesics , adverse effects and or tolerance to Opioids ineffectiveness ,inadequate time to assess pain Untreated pain leads to a vicious cycle of sleeplessness , worry , despair , isolation , hopelessness , depression and escalation of pain In palliative care medicine pain is one of the more treatable symptoms and a common reason for referral to specialist palliative care teams

 

What causes pain -Neurophysiology of cancer pain is complex Pain can happen at multiple anatomical sites and can involve mechanisms as 
○ inflammatory
○ neuropathic
○ ischaemic 
○ compression
○ chemotherapy induced neuropathy
○ radiation induced mucositis
○ para neoplastic neuropathy and arthropathy Pain can be of nociceptive , visceral or a mixed type with combination of all three Nociceptive pain includes bone pain and soft tissue pain and is typically described as a dull , aching pain . It is usually well localised. Neuropathic pain due damage to peripheral nerves or CNS and can be intractable and difficult to control Visceral pain symptoms include diffuse poorly localised pain with different descriptors as spasm , heavy feeling Cancer pain shares the same neuro-pathophysiological pathways as non cancer pain

 

Approach to pain management -Accurate comprehensive assessment and reassessment ( consider at each
visit ) is essential in management as many pains change with time Let the patient describe her / his own pain ( one pain or ? multiple pains )
◘ there may be more than one pain ( multiple pains are common ) Persistent / breakthrough pain ( breakthrough pain is a transitory flare up of moderate to severe pain in patients with otherwise stable persistent pain Not all pain is of malignant origin and if more than one pain is present each must be individually assessed and evaluated Tools as rating scales or visual analogue scales / QoL measurement tools / Pain diary- can be helpful in assessing severity of pain and response to treatment Psycho social assessment should be part of the routine evaluation Total pain is a term often used in palliative care to prompt HCPs to consider all possible influences on the pain experience ie physical , social , spiritual & psychological Consider appropriate investigations to try and determine the cause of pain Where possible treat reversible causes ( exclude conditions as infection , fracture , spinal cord compression ) Accurate record keeping is vital Physical examination/investigations should be carried to assist in finding the diagnosis / cause of pain.

 

Pain assessment -onset , intensity, severity constant or intermittent timing and duration , frequency , variation character / description ( for e,g burning, tingling , throbbing ) site , radiation aggravating & relieving factors effect of pain on function and ADL’s, QoL , psychological well being , social impact , spiritual impact pain expectations current and previous medications associated symptoms and features if patient has cognitive impairment consider behavioural assessment which can include noticing ( + self-report , physical examination , caregiver reports )
○ autonomic changes
○ facial expressions
○ body movements
○ verbalisations or vocalisations
○ interpersonal interactions
○ activity patterns Tools as DisDAT , Abbey , Dolphus, PAIN-AD – could be used for behavioural assessment ask about patients understanding , fears & concerns.

 

Step 1- for mild pain start regular paracetamol 1 gm qds ( can use oral ,via PEG , rectal, IV ) paracetamol is helpful across the range of pain and severity consider reducing dose to 500 mg qds if poor nutritional status , low body weight for e.g < 50 kgs , hepatic impairment and or chronic alcohol misuse history stop paracetamol if clearly not effective NSAID ( r/o CIs ) and evaluate risk /benefit balance and consider co-prescribing a PPI, f1st line NSAID can be Ibuprofen 400 mg tds

 

Step 2-weak opioid include codeine , dihydrocodeine and Tramadol codeine 30 mg to 60 mg qds or dihydrocodeine 30-60 mg qds codeine ( pro-drug ) works by changing to morphine. Some patients who are slow metabolisers ( 5 % to 10 % ) may produce little or no morphine and may not benefit whereas fast metabolisers ( 1 % to 2 % ) produce greater than usual amounts of morphine which may cause opioid toxicity Dihydrocodeine is an active substance and its effect is not dependent on metabolism combination ( codeine + paracetamol ) as co-codamol 30/500 , 2 tablets qds constipation is a common SE of codeine -consider prescribing a laxative Tramadol is an alternative weak opioid , 50 mg of tramadol is about equivalent to 5 mg of morphine Tramadol also acts as a serotonin and noradrenaline reuptake inhibitor and can precipitate serotonin syndrome ( clonus , sweating , tremor , agitation and death in rare cases ) when used with other serotonergic drugs ( antidepressants and antipsychotics ) Use tramadol with caution in star 4/5 CKD and severe liver failure -consider increasing dose interval of IR preparation to 12 hrs and avoid modified release preparations

 

Step 3 –strong opioids include morphine , diamorphine , oxycodone , fentanyl , alfentanyl , hydromorphone , buperonorpine and methadone ( for specialist use only ) Morphine is the drug of choice ( except in renal impairment ) Stop any step 2 opioid ( codeine or DHC 60 mg qds is equivalent to about 24 mg of morphine in 24 hrs ) Constipation ( is a common SE- always prescribe a laxative ideally a stimulant laxative ) Nausea is also common- may occur when starting or increasing opioids , consider prescribing an anti-emetic for prn use Dry mouth is a common SE – advise trial of ice cubes , sugar free chewing gum, pineapple chunks and artificial saliva Drowsiness – can happen when initiating treatment or when the dose is increased ,usually transient and reduces in a few days
 ( always exclude opioid toxicity ) Respiratory depression – is rare if titrated correctly Tolerance and addiction are not significant problems in patients at the end of life For patients who are elderly , cachexic and those with renal impairment -use lower doses , reduced frequency or alternative opioids.

References

  1. Hagarty, A.M., Bush, S.H., Talarico, R. et al. Severe pain at the end of life: a population-level observational study. BMC Palliat Care 19, 60 (2020). https://doi.org/10.1186/s12904-020-00569-2
  2. Jon Raphael, MB, ChB, MSc, FRCA, MD, FFPMRCA, Sam Ahmedzai, BSc, MB, ChB, FRCP, Joan Hester, MB, BS, FRCA, MSc, FFPMRCA, Catherine Urch, BM, MRCP, PhD, Janette Barrie, RN, MSc, John Williams, MB, BS, FRCA, FFPMRCA, Paul Farquhar-Smith, MB, BChir, FRCA, PhD, FFPMRCA, Marie Fallon, MB, ChB, MD, FRCP, MRCGP, Peter Hoskin, BSc, MRCS, LRCP, MB, BS, FRCR, MD, FRCP, Karen Robb, BSc, PhD, MCSP, Michael I. Bennett, MB, ChB, MD, FRCP, FFPMRCA, Rebecca Haines, DClinPsych, Martin Johnson, MB, ChB, MRCGP, Arun Bhaskar, MBBS, FRCA, FFPMRCA, Sam Chong, BSc, MBBS, MD, Rui Duarte, BSc, Elizabeth Sparkes, BSc, Cancer Pain: Part 1: Pathophysiology; Oncological, Pharmacological, and Psychological Treatments: A Perspective from the British Pain Society Endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners, Pain Medicine, Volume 11, Issue 5, May 2010, Pages 742–764, https://doi.org/10.1111/j.1526-4637.2010.00840.x
  3. Palliative Care Pain & Symptom Control Guidelines For Adults – Greater Manchester and Eastern Cheshire Strategic Clinical Networks *Palliative-Care-Pain-and-Symptom-Control-Guidelines.pdf (england.nhs.uk)
  4. American Society for Pain Management Nursing and Hospice and Palliative Nurses Association Position Statement: Pain Management at the End of Life https://doi.org/10.1016/j.pmn.2017.10.019

  5. WHO Palliative Care Palliative Care (who.int)
  6. Scottish Palliative Care Guidelines Scottish Palliative Care Guidelines – Pain Management
  7. A Guide to Symptom Management in Palliative Care Supported by Health Education England *YH-Palliative-care-symptom-guide-2016-v6.pdf (lindseylodgehospice.org.uk)
  8. Palliative Care Symptom Control Guidelines Adapted from Greater Manchester Strategic Clinical Network Guidelines Wirral University Teaching Hospitals *WirralPalliativeCareSymptomControlguidelinesPainV1.pdf
  9. North of England Cancer Network Palliative Care Guidelines *Layout 1 (twca.org.uk)
  10. Wessex Palliative Physicians  -The Palliative Care Handbook *Microsoft Word – GB 9th ed Final June 2019.docx (ruh.nhs.uk)

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