Pain Management
In the Palliative Care Setting
M. Thomas Beets MD
Objectives:
• Recognize the importance of cultural differences when
developing pain management approaches to patients and
families
• Have more insight into the multimodality approach to pain
management
• Identify symptoms occuring in palliative care patients in order
to evaluate the various treatment options
• Understand ongoing research in pain management of the
palliative patient
Three Steps
• Assess the cause of the pain (may be multiple
causes)
• Treat each type of pain
• Reassess continuously, expecially if pain
uncontrolled
Categories of Pain
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(P)Physical
(A)Emotional
(I)Social or interpersonal
(N)Spiritual or existential
Assessment
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History
Character of the pain
Physical
Pain assessment scale
Lab
Imaging
Bone Pain
• Intensifies on movement (Incident pain)
• Tender to palpation
• Deep and aching
Neuropathic Pain
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Shooting
Burning
Paresthesias-tingling
Stabbing
Scalding
Often follows sensory nerve distribution
May have allodynia (pain from light touch)
Raised Intracranial Pressure
• Generalized or posterior head pain
• Nausea
Visceral Pain
• Spasms
• Cramping
• Colicky
• Consider anticholinergics
Opioids
• Respiratory depression not usually clinically
significant
• Physical dependence is not addiction
• Tolerance verses disease progression
• Very wide effective dose range
• Are effective by mouth
• Rare to have euphoria in palliative patients
WHO 3-Step Ladder
Step 3, Severe Pain
Morphine
WORLD HEALTH ORGANIZATION
Step 2, Moderate Pain
Hydromorphone
Methadone
Fentanyl
Acet or ASA +
Oxycodone
Codeine
+ Nonopioid
analgesics
Hydrocodone
Step 1, Mild Pain
Aspirin (ASA)
Acetaminophen
(Acet)
Nonsteroidal antiinflammatory drugs
(NSAIDs)
+ Adjuvants
Oxycodone
+ Adjuvants
+ Adjuvants
Equianalgesic Doses of Opioid Analgesics
PO, SL
Parenteral
100
Codeine
60
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Fentanyl
0.1
15
Hydrocodone
4
Hydromorphone
1.5
150
Meperidine
50
10
Methadone
5
15
Morphine (MS Contin, Morphine,
Kadian, Avinza, MSIR, Roxanol)
5
10
Oxycodone (Percodan, Percocet,
Oxycontin, Oxyfast, OxyIR)
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1mcg/hr Fentanyl = 2 mg morphine/24 hours
Education on Palliative and End of Life Care 2007
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Equianalgesic Example
• 40 yr old male, Lung Ca & Bone mets,
severe pain
Current:
mg/24 hrs
Morphine Equivalent
MS Contin 400 mg TID
=1200 mg/24 hrs
Duragesic 2 100 mcg patches
= 400 mg/24 hrs
Roxanol 20 mg/ml
x 10 doses of 1ml = 200
Morphine Equivalent Total (Oral)
mg/24 hrs
Equianalgesic Dose, one-third for IV use
IV/Subcut Morphine Rate, divide by 24 hrs
=1800
=600 mg/24 hrs
=25 mg/hr
Principles
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Work with oral morphine equivalents
Give around the clock
Limited cross-tolerance
Opioid rotation
Begin with low dose
In elderly begin with ½ the usual dose
Titrate
Q 4 hr booster is 10% of 24 hr dose
Principles
• Avoid meperidine-metabolized to
normeperidine with 15-20 hr ½ life
• Avoid pentazocine-inhibits analgesia of
morphine
• Avoid IM
• Treat constipation-softening agent and
stimulant, avoid bulking agents
Principles
• Severe liver disease-opioids and
benzodiazepines will have delayed
metabolism (avoid methadone and
acetominophen)
Bone or Soft Tissue Pain
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Opioids
NSAIDS
Steroids
Calcitonin
Radiosotopes
biphosphonates
Neuropathic Pain
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Tricyclic antidepressants
Anticonvulsants
Local anesthetics
Baclofen
Capsaicin
Raised ICP
• Steroids
Visceral Pain
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Oxybutinin 5-10 mg po tid
Hyoscyamine 0.125mg 1-2 po or sl q 4 hrs prn
Transdermal scopolamine
Glycopyrrolate 0.2 mg IV, subcut q 4 hrs
Other modalities
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Distraction
Meditation
Massage
TENS
Acupuncture
Other Pearls
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Ketamine
Steroids
XRT
Most opioids are effectively absorbed from the
rectum
Transdermal, transmucosal, subcut, IV
Epidural or intrathecal analgesics
Ketorolac
Lorazepam
Bibliography
• EPEC (Education in Palliative and End-of-life Care),
Education of all healthcare professionals on the
essential clinical competencies in palliative care.
www.epec.net
Storey P, Knight C, UNIPAC Three: Assessment and
Treatment of Pain in the Terminally Ill. 2nd ed.
New York:Mary Ann Liebert, 2003.
• WHO Ladder: Cancer Pain relief and Palliative
Care. Technical Report Series 894. Geneva: World
Health Organization; 1990.