Transcript Let`s Talk About Pain

Let’s Talk About Pain
Karen Cox-Seignoret
M.B.,B.S., M.R.C.G.P.
What is pain?
Pain is…

An unpleasant sensory and emotional
experience caused by actual or potential
tissue damage

Any unpleasant bodily sensation; mental
suffering
Physical Pain
Total Pain
WHAT’S DIFFERENT ABOUT
CANCER PAIN?
The meaning of the pain
The Problem of Pain

Pain is what the patient says hurts

75% of patients with advanced cancer
experience pain

Worldwide half of those dying are in
uncontrolled pain

Cancer pain can be relieved in 70-90% using
a simple opioid regimen.
What Causes Pain?

Painful stimuli act on specialized nerve
endings (nociceptors)

Inflammatory cells, neurotransmitters and
other chemicals are released

Messages are sent to the spinal cord and
thence to the thalamus, hypothalamus and
cerebral cortex
Types of pain

Somatic/visceral
usually opioid sensitive

Bony
usually NSAID sensitive

Neuropathic
may be poorly responsive to opioids
try adjuvant agents
40-50% cancer pain
Pain Assessment

Assess the cause of the pain:
related to the cancer, related to the
treatment, unrelated to either

Assess the type of the pain
(somatic, visceral, bony, neuropathic)

Assess pain severity
Where to start?
Or these?
Immediate Release Morphine
Or maybe these?
WHO Analgesic Ladder
WHO Analgesic Ladder
Drugs

Step 1 Non-Opioids
e.g. paracetamol, NSAID’s

Step 2 Weak Opioids
e.g. codeine, dihydrocoedein, tramadol

Step 3 Strong Opioids
e.g. morphine, diamorphine, fentanyl, oxycodone,
methadone
Adjuvant Analgesics

Are not analgesics in their own right, and are
used primarily for other indications, but can
produce analgesia in certain circumstances.
Adjuvant Analgesics




Antidepressants
e.g. amitriptyline
Anticonvulsants
e.g. carbamazepine, sodium valproate,
gabapentin, pregabalin.
Membrane stabilizers
e.g. flecainide, mexilitine
Corticosteroids
Locally Available Opioids
Codeine

Weak opioid

Effective as a cough suppressant and
antidiarrhoeal agent

Compounds: panadeine, panadeine F,
paracodeine.
Tramadol

Less constipation and respiratory depression
than Morphine

May have a role in neuropathic pain

Trabilin, Tramacet
Pethidine

NOT appropriate for chronic pain

Accumulation of metabolites with adverse
CNS side effects

Duration of action 3-4 hours only
NIL IN STOCK
NIL IN STOCK
Global Consumption of Morphine, 2010
mg/capita
TT’s morphine use per capita:
75% below world average!
Global Mean
5.9912
T&T
1.54
152 countries
**Austria’s consumption includes use of morphine for substitution therapy
Sources: International Narcotics Control Board; World Health Organization population data
By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2012
Myths
Patient
will get hooked on morphine
Addiction (psychological dependence), is rare
(4 cases per 12,000)when opioids are used for
severe pain.
Myths
 Dangerous
respiratory depression is likely
 If
started too early, morphine will not be
effective later ,when really needed
 Morphine
will speed up death
Strong Opioids
“Exist to be given, not merely to be
withheld”
Guidelines for Opioid Use
WHO Guidelines*

BY MOUTH

BY THE CLOCK (regularly and not prn)

BY THE LADDER
WHO (1986) Cancer Pain Relief. WHO, Geneva
WHO (1996) Cancer pain Relief : with a guide to opioid availability. WHO Geneva.
Guidelines for Opioid Use
 Address breakthrough pain
 Anticipate Nausea
-antiemetic e.g. metoclopramide for 4-5
days
 Anticipate Constipation
- stimulant laxative e.g. senna or bisacodyl
Guidelines for Opioid Use
 Anticipate
pain – give analgesia 30min
before an activity known to cause pain
 Review dosing regularly!
Difficult to control pain
Review the cause
 Is it opioid sensitive?
DO NOT INCREASE THE OPIOID DOSE IF
NOT.
 Consider adding adjuvant agent,
 Consider other options - surgery,
radiotherapy, bisphosphonates.

Non-Drug Therapies
TENS
 Nerve blocks
 Physical therapy
 Radiotherapy
 Complementary & Alternative Therapies –
Acupuncture, relaxation techniques,
hypnotherapy, aromatherapy massage.

The Declaration of Montreal
Access to Pain Management is
a Fundamental Human Right.
Governments are obliged to establish laws,
policies and systems to promote adequate
pain management.
“I must tell him, the doctor, that he must think of something else.
It is impossible, impossible to go on like this.”
Leo Tolstoy, the death of Ivan Illych
THANK YOU