PAIN MANAGEMENT IN PALLIATIVE CARE

PAIN MANAGEMENT IN PALLIATIVE CARE:

PAIN MANAGEMENT IN PALLIATIVE CARE DR.S.SREENIVASARAO MD,C.C.P.P.M, ASSIST PROFESSOR, DEPT.OF ANAESTHESIA, S.V.R.R.G.G.H.&S.V.M.C, TIRUPATI

DRUGS USED FOR PAIN:

DRUGS USED FOR PAIN THREE GROUPS OPIOID ANALGESICS NON-OPIOID ANALGESICS ADJUVANT ANALGESICS

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Oral Morphine is the drug of choice for severe cancer pain - WHO

ACTION:

ACTION Activating opioid receptors in the midbrain & turning on the Descending inhibitory system Activating opiod receptors on the second order pain transmission cells to prevent the Ascending transmission of pain signals Activating opioid receptors at the central terminals of C fibers in the spinal cord Activating opioid receptors in the periphary to inhibit the activation of nociceptors & to inhibit cells that may release inflmmatoy mediators

RESPONSE MEDIATED BY ACTIVATION OF OPIOID RECEPTORS:

RESPONSE MEDIATED BY ACTIVATION OF OPIOID RECEPTORS RECEPTOR RESPONSE ON ACTIVATION MUE ANALGESIA,RESP.DEPRESSION, MIOSIS,EUPHORIA, REDUCED GI MOTILITY KAPPA ANALGESIA,DYSPHORIA, PSYCHOTOMIMETIC EFFECTS MIOSIS,RESP.DEPRESSION DELTA ANALGESIA

OPIOID ANALGESICS:

OPIOID ANALGESICS CLASSIFICATION AGONIST AGONIST-ANTAGONIST MORPHINE PENTAZOCINE CODEINE,OXYCODONE BUTORPHANOL DIHYDROCODEINE NALBUPHINE OXYMORPHONE DEZOCINE PETHIDINE,METHADONE MEPTAZINAL HYDROMORPHONE FENTANYL PARTIAL AGONIST DIAMORPHINE(HEROIN) BUPRENORPHINE TRAMADOL ANTAGONIST NALOXONE NALTREXONE

Preparations:

Preparations Morphine Inj Tablets liquid Fentanyl Inj Transdermal patches Oral Transmucosal Under clinical trials Nasal spray Inhalations

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ORAL MORPHINE

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Poppy flower

:

Rajasthan MP UP Poppy cultivation in India

The Sad Indian paradox:

The Sad Indian paradox 2 million Indians like him need oral morphine for pain relief. It reaches less than 1% of the needy

Preparations of Oral Morphine Tablets (MST):

Preparations of Oral Morphine Tablets (MST) Immediate Release 10mg, 30mg, 60mg Sustained Release 10mg, 30mg Liquid Morphine Oral Morphine

How to use:

How to use Start with 5 - 10mg i/r MST Always use q4h with double dose at bed time Additional doses can be given p.r.n. for breakthrough pain If pain relief is not satisfactory, increase by approximately 50% of previous dose Oral Morphine

Breakthrough dosing :

Breakthrough dosing When flares of pain last for more than few minutes, extra doses of analgesics may be helpful For each breakthrough dose, offer 5% to 15% of the 24-hour dose A breakthrough dose can be offered once Cmax has been reached

How to use:

How to use There is no maximum dose of morphine; the dose can be increased depending on the severity of pain “Pain is the physiological antagonist to the central side effects of morphine.” Oral Morphine

How to use:

How to use Always prescribe a laxative (stimulant +/- softener) prophylactically “The hand that prescribes the Morphine should also writes laxatives” Prescribe an anti-emetic prophylactically for the first few days , especially in patients who are already vomiting Oral Morphine

Exceptions to ‘every four hours’:

Exceptions to ‘every four hours’ Renal failure Very elderly > 70 yrs increase dosing interval decrease dosage size Accumulation of M6G leads to enhanced opioid toxicity. Oral Morphine

Exceptions to ‘every four hours’:

Occasional attacks of severe pain Night pain only Oral Morphine Exceptions to ‘every four hours’

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Initial: Nausea and vomiting Drowsiness Unsteadiness Oral Morphine - Adverse effects

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Continuing: Constipation Nausea and vomiting Inactivity drowsiness Dry mouth Oral Morphine - Adverse effects (cont.)

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Occasional: Urinary retention Myoclonus Itching Oral Morphine - Adverse effects

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Signs of overdose: Drowsiness Delirium Myoclonus Oral Morphine - Adverse effects

Misunderstandings about morphine:

Misunderstandings about morphine ‘Morphine is dangerous because it depresses respiration’ Double dose at bed time does’nt cause RD Large therapeutic window Drowsiness and delirium prevents from taking further dose Tolerance to respiratory depression develops in course of time Oral Morphine

Misunderstandings about morphine (contd):

Misunderstandings about morphine (contd) ‘Morphine is addictive’ Several studies have concluded that risk of addiction is far less than 1% Two studies with more than 500 patients who received Heroin for pain relief found that no patient could be documented as having become addicted Twycross, 1974; Twycross, Wald, 1976 Prospective study of 11,882 hospitalised medical patients only 4 patients could be documented as having become addicted as a result of receiving opioid analgesics Porter, Jick, 1980 Oral Morphine

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Oral Morphine Results of 2 year study in India

Opioid dependence:

Opioid dependence Physical Psychological dependence dependence (withdrawal symptoms) (addiction) Diarrhoea, palpitation Craving and sweating unsanctioned dose loss of other interests

MNJ experience::

MNJ experience: Addiction: Total no. of patients seen since December 2003- More than 6000 subjects One patient had ? Addiction with h/o high risk behavior Oral Morphine

Other misunderstandings about Morphine:

Other misunderstandings about Morphine ‘Morphine induces euphoria’ What happens if a person with no pain takes oral morphine? Pharmaco-kinetics of oral morphine Oral Morphine

Other Misunderstandings about Morphine:

Other Misunderstandings about Morphine ‘ Tolerance to morphine develops rapidly’ ‘ If a cancer patient is given morphine, he is going to die soon’ Oral Morphine

Other Indications:

Other Indications Intractable Cough Dyspnoea Intractable diarrhoea Oral Morphine

Conclusions:

Conclusions Oral morphine is the drug of choice for severe cancer pain management It is always safe in “safe hands” Respiratory depression, addiction and tolerance are not problems with oral morphine Oral Morphine

Fentanyl:

Fentanyl Convenient 25 times expensive Not useful for break through pain Latency of action Acts up to 24 hrs after removal of patch Titration not possible if the patient becomes drowsy Practically no role as first line It works better in cool climate

NON OPIOID ANALGESICS:

NON OPIOID ANALGESICS PARACETAMOL NSAIDS

Paracetamol:

Paracetamol Mechanism of action : Anti pyretic Central – inhibits cox in the CNS - intracts with several other central mechanisms like Opioidergic & serotinergic Peripheral analgesic effect No anti inflammatory action

Paracetamol:

Paracetamol ADVANTAGES DRAWBACKS No Injurity to Gastric mucosa No nephrotoxicity No platelet dysfunction It can be taken by 2/3 rd of patients hypersensitive to aspirin/NSAIDS Safe up to 6-8 g/day Large doses 20mg/m 2 Large size tablets Frequency of administration 4-6 th hourly Hepatotoxicity

NSAIDS:

NSAIDS INHIBIT THE CYCLO-OXYGENASE PHOSPHOLIPIDS ARACHIDONIC ACID PG’S PG’S STOMACH INFLAMMATION PLATELETS STOMACH INTESTINES,KIDNEY KIDNEY BONE,BRAIN COX-1 COX-2 TISSUE DAMAGE PHYSIOLOGICAL STIMULUS CONSTITUTIVE INDUCIMLE

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NSAIDS INHIBIT THE CYCLO-OXYGENASE DECREASING SYNTHESIS OF PROSTAGLANDINS REDUCES THE PAIN SENSITIZING EFFECT OF PG’S ANTI-INFLAMMATORY AND ANTIPYRETIC EFFECTS &

ADVERSE EFFECTS:

ADVERSE EFFECTS GIT ---ULCERATIONS BLOOD---INHIBITION OF PLETELET AGGREGATION KIDNEY---FLUID &POTASSIUM RETENTION ALL THE ABOVE EFFECTS LEADS TO THREE MAJOR PROBLEMS GI BLEEDING RANAL FAILURE CONGESTIVE HEART FAILURE COMMONLY USED DRUGS IBUPROFEN,DICLOFINAC,KETOROLAC,NAPROXEN,PIROXICAM SELECTIVE COX-2 INHIBITORS---CELECOXIB,VALDECOXIB,ROFECOXIB,ETORICIXIB

ADJUVANT DRUS:

ADJUVANT DRUS Not analgesics, but relieve pain in specific situations Drugs to control the undesirable effects of analgesics Concurrently prescribed psychotropic medication

ADJUVANTS:

ADJUVANTS Antidepressants like TCA Anti-epileptics NMDA receptor channel blockers Corticosteroids Antispasmodics Muscle relaxants Bispsphonates Radiation

Nonpharmacologic techniques:

Nonpharmacologic techniques neurostimulatory techniques physical therapy psychological approaches art or music therapy massage and body work, etc acupuncture, acupressure, etc.

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THANK YOU