Pain
The concept of total pain

Factors which increase pain

  • Other symptoms/side effects
  • Fatigue
  • Insomnia
  • Depression/loss
  • Isolation
  • Anger
  • Anxiety /Fear
  • Spiritual distress
  • Environment

Factors which decrease pain

  • Relief of other symptoms
  • Sleep
  • Understanding/Sympathy
  • Companionship
  • Diversion
  • Creative activity
  • Relaxation/visualisation
  • Environment
Assessment of pain
  • History
  • Duration
  • Description
  • Factors which increase pain
  • Factors which decrease pain
  • Analgesia history
  • What is the patient’s aim?
  • What is the family’s aim?
  • Continual reassessment

The WHO 3-step analgesic ladder

World Health Organization (1986) Cancer Pain Relief.Geneva: WHO

Principles of pain control

  • By the clock
  • By the ladder
  • By mouth
  • Set goals with the person & their family
  • Individual dose titration
  • Use adjuvant drugs
  • Pain may be:-

Responsive to opioids

Semi-responsive to opioids

Unresponsive to opioids

Routes of administration

  • Oral/Sublingual/buccal
  • Subcutaneous infusion or regular injections
  • Transdermal patches
  • Rectal/ Spinal

Non opioids

  • Paracetamol
  • NSAID

Adjuvants

  • Corticosteroids
  • Antidepressants
  • Anti-epileptics
  • Smooth muscle relaxants(antispasmodics)
  • Skeletal muscle relaxants
  • Bisphosphonates

Opioids ‘weak’

  • Codeine
  • Dihydrocodeine
  • Tramadol

Opioids ‘strong’

  • Morphine
  • Oxycodone
  • Diamorphine
  • Fentanyl
  • Methadone
  • Hydromorphone
  • Buprenorphine

Side effects of opioids

Common initial side effects

  • Nausea/vomiting
  • Drowsiness
  • Lightheadedness/unsteadiness
  • Delirium(acute confusional state)

Common ongoing side effects

  • Constipation
  • Nausea/vomiting
  • Dry mouth

Less common side effects

  • Neurotoxicity -myoclonus,allodynia,hyperalgesia
  • Cognitive failure/delirium, hallucinations
  • Sweating
  • Pruritus
  • Nightmares/dysphoria

Rare side effects

  • Psychologicaldependence
  • Respiratory depression. Naloxone is rarely needed in palliative care patients as compared to post operative patients

Specific pain syndromes

Neuropathic pain

  • “Burning”, “stabbing”, “shooting”, “numb” or “tingling”
  • Semi-responsive to opioids – methadone or oxycodone may help
  • Antidepressants/Anticonvulsants e.g. amitriptyline, gabapentin, pregabalin
  • Clonazepam may help
  • Steroids occasionally help
  • Ketamine under specialist supervision
  • Nerve blocks
  • Spinal analgesic
  • Cordotomy

Bone pain

  • Often “aching”
  • Worse on movement
  • Radiotherapy
  • NSAIDs
  • Opioids
  • Bisphosphonates/Denosumab

Colic

  • “Cramping”, “spasm”
  • “Comes & goes”
  • May be related to constipation, bowel or ureteric obstruction
  • Buscopan – antispasmodic/antisecretory
  • Octreotide – antisecretory if bowel obstructed

Liver capsule pain

  • “Aching” in the right side of the abdomen
  • Possible referred pain into the shoulders & back
  • Dexamethasone/NSAIDs may help

Pain associated with breathing

  • May be worse on inspiration or due to generally laboured breathing
  • Treatment of the cause may help pain e.g. chest infection, pulmonary embolus, pleural effusion, rib fracture or metastasis
Painful procedures
  • Oramorph
  • Diamorphine
  • Entonox
  • Midazolam
  • Fentanyl SL Buccal

Headache

  • Paracetamol/codeine
  • Headache due to cerebral disease or raised intracranial pressure may be helped by dexamethasone & radiotherapy
  • Morphine is often ineffective, and in some cases may worsen headache

Renal impairment - check STH renal guidelines for suitable analgesics and doses

Use of drugs ‘off-label’ in palliative care

  • In palliative care up to a quarter of all prescriptions are for licensed drugs given for unlicensed indications and/or by an unlicensed route. This is known as ‘off-label’ prescribing.
  • Thelicensing process provides a marketing authorisation which sets out the purposes for which the drug may be marketed. Once marketed, further trials often reveal other indications for drugs. However, the considerable cost of relicensing means that licensed drugs are generally not relicensed for other purposes.
  • The use of drugs beyond license should be seen as a legitimate aspect of palliative care practice.
  • Prescribers should select those drugs, in the light of published evidence, that offer the best balance of benefit against harm & should work in partnership with patients to gain their consent when recommending a drug ‘off-label’.
  • It is recommended that prescribers should document their reason for choosing a drug ‘off label’ although in reality this is likely to be impractical as this practice is so widespread (PCF3).

Other approaches to pain control

  • Radiotherapy
  • Chemotherapy
  • Orthopaedic or other surgery
  • Acupuncture
  • Nerve blocks
  • Relaxation/visualisation
  • TENS
  • Comfort measures
  • Conserving energy
  • Massage

Useful sources of information regarding pain management and titration/conversion of opioids

  • BNF British National Formulary
  • PCF5(2015) Palliative Care Formulary. 5th edition. (Twycross, R & Wilcock, A). Nottingham: Palliativedrugs.com
  • Sheffield Palliative Care Formulary (2015)
  • St Lukes Hospice Community Specialist Palliative Care Team (Tel.2369911)
  • STH Specialist Palliative CareTeamvia the hospital switchboards.
  • Palliative Care Pharmacists
  • STH Medicines Information 2712346/2714371