Pain Management in Terminal Illness

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Pain Management in Terminal Illness

• P. Chaudakshetrin M.D.

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Effective pain management in terminally ill
requires

• Understanding of pain control strategies
• Ongoing assessment
• Diagnosis of pain
• Breakthrough pain relief
• Fine adjustment of medications
• Opioid rotation
• Unresolved psychosocial or spiritual issue can be
  great impact to pain management

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• Patient dying from nonmalignant disease suffer
  similar level of pain to those found in patient
  with malignant disease
• People at particular risk for undertreatment
• Older adults
• Minorities
• Women

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Goals of Pain Management

• In cancer
• gt 80 will achieve good control
• 15 will have fair control
• lt 5 will have poor or no control

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Principle of pain control at end-of-life

• Pain can be mostly controlled by WHO step-care
  approach
• Acute or escalating pain is the medical emergency
  that require prompt attention
• Addiction is not the issue in patients with
  terminal illness

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The WHO Analgesic Ladder
SEVERE PAIN
Morphine Fentanyl Methadone
MODERATE PAIN
Codeine Tramal
MILD PAIN
Aspirin Acetaminophen NSAIDs
Co-analgesics Drugs, nerve blocks, TENS,
relaxation, acupuncture
Specific therapies Radiotherapy,
chemotherapy,surgery

• Address psychosocial problems

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Multifactorial Nature of Cancer Pain
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Advanced Rectal cancer s/p palliative colostomy,
large pelvic mass involved bony structure,
incarcerated peri-anal erosion multiple lymph
node metastasis. fecal incontinence,

• Stocking like dysesthesia,
• Diminished pinprick sensation
• Slight motor weakness

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Pain problems has to be diagnosed and
differential diagnose
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BACK PAIN Differential diagnosis

• Local invasion of pancreatic cancer to parietal
  peritoneum, celiac ganglion,
• Visceral referred pain
• Metastasis bone pain
• Enlarged Aortic lymph node
• Concurrent degenerative bone disease
  spondylosis, spondylolithiasis, spinal stenosis

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Available evidence for pain treatments
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Neuropathic VS Nociceptive pain

• NOCICEPTIVE pain

• NEUROPATHIC pain

• Tissue damage
• Activation of peripheral nociceptive nerve
  terminals
• Impulse conduction and synaptic processing
• Pain

• Damage to the nervous system
• Loss of function
• Ectopic activity within the nociceptive system
• Impulse conduction and synaptic processing
• Pain

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Characteristic of cancer pain
PAIN

• Acute Pain
• Follows injury...resolves
• Objective physical signsCOMMON
• Chronic Pain--cancer, term. illness
• Objective signs RARE
• Patient may not look like he/she is in pain

Persistent Pain (Back ground)
Breakthrough Pain
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Characteristic of cancer pain
PAIN

• Nociceptive
• Somatic bone/soft tissue tender, deep,
  aching
• Visceral spasms, cramping, gnawing
• Neuropathic or Deafferentation
• shooting, stabbing, burning paresthesias,
  hypesthesias, allodynia

Persistent Pain (Back ground)
Breakthrough Pain
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Abdominal Visceral Pain
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VISCERAL PAIN is different from SOMATIC PAIN

• Cutaneous
• Muscle
• Visceral

• Pricking
• Stabbing
• Burning

• Aching
• Cramping

Poorly Localized
Inconsistent sensations, often inescapable,
sometimes referred

• Fullness
• Dullness
• Vague

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Nociceptive pain
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Sqaumous cell CA of lips
Squamous cell CA of skin
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Pathological mechanisms of mixed pain state
Tissue/ organs
Nociceptive component Sprouting from C-Fibres
into the disc
C Fibre
Neuropathic component I Damage to a branch of
the C Fibre due to compression and inflammatory
mediators
Tumor growth
C Fibre
A Fibre
Neuropathic component II Compression of nerve
root
Neuropathic component III Damage to nerve root
by inflammatory mediators
Central sensitisation
Baron R, Binder A. 2004 Orthopade 2004 33
568-75.
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NEUROPATHIC PAIN2 types

• .Continuous dysesthesias
• continuous burning, electrical sensations or
  other abnormal sensations.
• Chronic lancinating or paroxysmal pain
• sharp, stabbing, shooting, knifelike pain,
• often with a sudden onset.

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Etiologies
COMMON
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Etiologies
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Physiological Responses to Repetitive
Nociceptive Input

• Windup
• highly augmented response to repetitive
  afferent (C-fiber) input
• Neuronal plasticity
• changes in the CNS in response to repetitive
  afferent nociceptive input

Herrero JF et al. Wind-up of spinal cord neurons
and pain sensation much ado about something?
Prog Neurobiol. 2000611690203. Mao J, Mayer
DJ. Spinal cord neuroplasticity following
repeated opioid exposure and its relation to
pathological pain. Ann N Y Acad Sci.
2001933175-84.
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Signs and Symptoms of Chemotherapy-induced
Peripheral Neuropathy
Adapted from Paice, Visovsky, and Quasthoff and
Hartung
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Metastasis to Bone are Common

• Most Common form of cancer related pain (75)
• 100,000 Cancer pts. / yr
• Poor prognostic factor
• Correlates with anxiety, depression morbidity
• Poor control of breakthrough aspect of cancer
  bone pain with current pharmacological treatments

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Causes of pain due to bone metastases

• Activation of nociceptors by tumor
• Sensitization of peripheral nerves spinal
  cord
• Inflammation
• Nerve damage
• Pathological fractures
• Spinal cord compression

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Peripheral Mechanisms

• Tumor cell releases chemical mediators of pain
• Immune cells do likewise
• PH lowered

• Osteoclast activation
• Stretch of bone
• Denervation
• Destruction of fibres

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Cancer Induces sensory changes

• Dorsal horn neurons are hyper excitable in CIBP
• Emergence of behavioral hyperalgesia and
  allodynia parallels altered neuronal response

PERIPHERAL ALTERATIONS DRIVE CENTRAL
HYPEREXCITABILITY
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Phantom pain vs Phantom sensation
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Types of pain due to bone metastases

• tonic background pain
• incident pain on movement
• spontaneous pain

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Breakthrough Pain Aspects and Subtypes
Idiopathic Stimulus Independent
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Incident Pain

• Pain occurring as a direct and immediate
  consequence of a movement or certain activity,
  rolling over in bed, riding in a car or being
  bathed.

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INCIDENT PAIN

• Management
• giving breakthrough dose of IR medication 30
  minutes before activity
• Premedication can reduce amount of pain that
  occurs during activity.
• Assess patients for underlying causes of the pain
• Correct causes if possible.

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• most challenging of cancer pains to control and
  highly debilitating to the patients functional
  status and QOL .2,3,4

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Barriers to Managing Incident Pain

• Common opioids outlast painful stimulus
• Opioid dose for incident pain may far exceed
  that needed for background pain control
• May be little warning of incident
• Effective premedication before activity is time
  consuming

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Assessing pain at the end of life

• The primary source of information in a pain
  assessment ? patient self-report
• In cognitive impairment patient ,self-assessments
  remain the cornerstone of pain management

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Pain Problem should be assessed

• Impeccable Pain Assessment

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Symptoms management

• Pain
• Even when the patient is close to death careful
  evaluation and assessment of pain including a
  history and examination where possible is still
  necessary
• It is important to exclude psychosocial issues
  which may cause exacerbations
• pain will not be troublesome at the very end if
  control has previously been good.

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A comprehensive evaluation of pain

• Intensity
• Character
• Frequency
• Onset
• Duration
• Location
• History of pain
• Physical and neurologic examination
• Psychosocial assessment

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• Way of expressing other forms of suffering
• Distress
• Grieving
• Anxiety
• depression

Psychosocial spiritual evaluation and
intervention will be more effective than
analgesics
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Listen with empathy to patients perception of
their pain
Explain your perception of pain problems
Ackowledge differences and similarities in
perceptions
Recommend treatment Negotiate agreement
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Diagnostic evaluation

• Test to determine the cause of pain
• Corroborate clinical impression of the cause of
  pain and mechanisms
• Neither delay empiric treatment nor add excessive
  burden to the patient

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Differentiating pain mechanisms at end of life

• Terminal stage ? multiple mechanism of pain
• Type of treatment and its success is largely
  dictated by the pain mechanism and its original
  source

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PAIN ASSESSMENT

• Extent of nociception / disease / impairment
• Magnitude of the suffering / quality of life
• Pain behaviours / psychological / social patterns

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The Process of Diagnosis

• Medical History
• Symptom assessment
• Verbal descriptors
• Pain scales
• Physical examination using simple bedside / in
  office instrumentation
• Diagnostic tests

EMG electromyography, NCS nerve conduction
studies
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Pain Assessment

• Listen carefully What are the words used?
• May deny pain but will admit to having
  discomfort, aching or soreness
• Do you hurt anywhere?
• Are you uncomfortable?
• How does it affect you?
• Believe the patient pain is what the patient
  says hurts.the best judge of a patients pain is
  the patient Bonica
• Assess for other symptoms Portenoy Study of 243
  cancer patients- Average of 11.5 symptoms

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Pain Assessment Tools

• OLD CARTS
• O Onset acute vs gradual
• L Location ( radiation)
• D Duration (recent/chronic)
• C Characteristics (quality of pain)
• A Aggravating factors
• R Relieving factors
• T Treatments previously tried - response
• - dose/duration
• - why discontinued?
• S Severity Pain Scales 0- 10 VAS

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Assess the Person, Not just the pain
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Please rate your pain by
circling the one number that best describes your
pain _____________________________________________
________________ 0 1 2
3 4 5 6 7 8
9 10 What is your Pain at its
Best / Worst/ Present/ Average0 1
2 3 4 5 6
7 8 9 10 No Pain


Pain as bad as

you can imagine
In the past 24 hours, how much RELIEF have
pain treatments or medications provided? Please
circle the one percentage that most shows how
much. ____________________________________________
_________________ 0 10 20 30
40 50 60 70 80 90 100
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Patient with advanced cancer is in dynamic state
Careful and Frequent Assessment is the key
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Take Home message
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Drug for pain relief in palliative care

• Principle of effective symptom control
• Diagnose the underlying cause of each symptom and
  tailor the treatment to individual circumstances
  and clinical context
• Influence factors for drug response
• Genetic factors
• Pathologic processes
• Concurrent medication
• aging

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• Determine the etiology of pain and the social and
  prognostic circumstances that will affect the
  pain experience and pain therapy
• Focus on discernible clinical end point
• Pain reduction
• Functional capacity
• Mood
• Sleep
• Relationships
• Pleasure in living

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• Match the mechanism of pain with the class of
  drug
• Initiate therapy and adjust dose according to
  therapeutic response, side effect, and known
  pharmacokinetics of the drug
• Anticipate and monitor for adverse effect
• Prevent side effect
• Actively treat side effects

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Pain Treatment Methods
Remove Causes
Psychological Methods
Medications
Regional Anesthesia
Physical Methods
Surgery Splinting Etc.
Non-opioids
Opioids
Nerve block Epidural block Catheterization Interve
ntional
TNS Acupuncture Physio Ice, US
Relaxation Manipulation Hypnosis
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To cure sometimes.To relief often.But to
comfort always.
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Management Considerations

• age-specific considerations
• Morphine often drug of choicenon-ceiling. Other
  nonceiling drugs include hydromorphone,
  levorphanol and methadone
• Use non-narcotic when able
• Combinations may work by different mechanisms
  thus greater efficacy (e.g. Tylenol w/codeine)

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Normal pharmacokinetics and pharmacodynamics may
be considerably altered by end-stage disease
states
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If the patient cannot swallow ?

• ROUTES
• SUBCUTANEOUS
• Continuous (Syringe driver)
• Intermittent (scalp vein needle)
• INTRAVENOUS
• RECTAL
• TRANSDERMAL PATCH
• EPIDURAL/INTRATHECAL

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Indications for Parenteral Opioids

• Inability to swallow
• Rapidly escalating pain
• Intractable adverse effects such as nausea with
  oral opioids
• Cognitive dysfunction

• Compliance problems
• Bowel obstruction
• Severe stomatitis
• Large doses of opioids with many tablets to
  swallow

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• Parenteral administration
• Intravenous route
• Rapid drug delivery
• Required vascular access
• Not be easily obtained or maintained in the home
  or long-term care setting
• Subcutaneous bolus
• Effective
• Slower onset ,lower peak effect
• Subcutaneous infusion
• As much as 10 ml/hr are usually absorbed
• Most patient tolerate 2-3 ml/hr with least
  difficulty

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Routes of administration
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Routes of administration (cont.)
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If the patient cannot swallow ?

• ROUTES
• SUBCUTANEOUS
• Continuous (Syringe driver)
• Intermittent (scalp vein needle)
• INTRAVENOUS
• RECTAL
• TRANSDERMAL PATCH
• EPIDURAL/INTRATHECAL

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If the patient cannot swallow ?

• CONVERSION
• Subcutaneous / IV ½ oral 24 hr dose.
• Rectal oral dose
• Transdermal patch 25 ug/ hr
• 60mg oral/24 hr
• 30mg subcut/24 hr
• Epidural 1/10 subcut/iv
• Intrathecal 1/100 subcut/iv

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Intraspinal route

• Epidural or intrathecal
• Equipment complex, required specialized knowledge
  for health care professionals
• Risk of infection
• Maintenance costs

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If the patient cannot swallow ?

• CONVERSION
• Subcutaneous / IV ½ oral 24 hr dose.
• Rectal oral dose
• Transdermal patch 25 ug/ hr
• 60mg oral/24 hr
• 30mg subcut/24 hr
• Epidural 1/10 subcut/iv
• Intrathecal 1/100 subcut/iv

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Opioids and route of administration
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Subcutaneous infusion of analgesic drugs

• Pain that may benefit
• Postoperative or other form of acute pain
• Patients with HIV/ AIDS
• Oncology and palliative care
• Chronic non-malignant pain
• Indications
• Unable to swallow oral medication
• Nil by mouth and previous taking oral morphine
• Unable to take oral morphine because intractable
  nausea and vomiting
• Unconscious paliative care patients who has been
  taking oral opioid

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Intrathecal Drug Delivery System For Chronic Pain
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• 2. Cancer Pain
• The principal indication is failure of
  conventional routes of administration of
  analgesics to achieve satisfactory analgesia
  despite escalating doses of strong opioids,
  and/or dose limiting side effects .
• The malignancy must be fully investigated with
  appropriate imaging techniques prior to a
  decision to undertake ITDD.

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Patient selection

• Patient selection is extremely important and
  should comprise a comprehensive
  multidisciplinary assessment
• Clinical symptoms and disease,
• Psychological- comprehensive psychological
  assessment
• i) assess possible concurrent
  psychopathology (e.g. severe affective disorder ,
  body dysmorphia, procedural fears) that might
  impede successful implantation
• ii) to consider what additional
  individualised preparation might be advisable for
  the patient.
• Social

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