Pain Management in Terminal Patients

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Pain Management inTerminal Patients

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Pain Assessment

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Pain Assessment

• Onset and temporal pattern
• Location
• Description
• Intensity
• Aggravating and relieving factors
• Previous treatment effect

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Assess disease/cancer

• disease/cancer location
• response to prior therapy
• other organs damage
• benefit or burden of further therapies
• prognosis
• final hours
• hours to days
• days to weeks
• weeks to months

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Mechanism-base pain
Pain
Mechanism-based approach
Nociceptive pain
Neuropathic pain
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Mechanism-base pain
Pain
Mechanism-based approach
Nociceptive pain
Neuropathic pain
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Neuropathic pain
Origin of pain Structure Example
Peripheral nervous system Nerve -Neuroma -Trigeminal neuralgia -Diabetic neuropathy -Phantom limb pain -Lumbosacral plexopathy
Peripheral nervous system Dorsal root -Postherpetic neuralgia -Brachial plexus avulsion
Central nervous system Spinal cord -Spinal cord injury -Spinal cord ischemia
Central nervous system Brain -Stroke -Brain tumor
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Clinical features ofneuropathic pain
Clinical features
Positive phenomena Autonomic dysfunction
Negative phenomena
Spontaneous pain
Evoked pain Sensory loss
Continuous Allodynia
thermal burning mechanical
vibration paresthesia
thermal touch
dysesthesia Hyperalgesia Paroxysma
l electrical, sharp, shooting
Vasomotor Sudomotor
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Multi-dimension
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Principles analgesic use

• WHO 3 -step analgesic ladder
• Oral route
• Adequate dose
• By clock
• prn for breakthrough pain
• Adjuvants
• Early detection and prompt treatment of side
  effects

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First line Medications
AMITRYPTYLINE
NORTRYPTYLINE
GABAPENTIN
CARBAMAZEPINE
OXCARBAZEPINE
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TRAMADOL
ORAL MORPHINE
PETHIDINE
VENLAFXINE
DULOXETINE
Second line Medications
PREGABALIN
PARACETAMOL, NSAIDS, COX-2 INHIBITORS
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TRAMADOL
ORAL MORPHINE
PETHIDINE
VENLAFXINE
DULOXETINE
Second line Medications
PREGABALIN
PARACETAMOL, NSAIDS, COX-2 INHIBITORS
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• physicians, patients and families fear about
  using opioids.
• good patients do not complain or need opioids.
• worsening pain is often a sign of worsening
  disease.
• separation curative care from palliative care

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Dependence

• Porter J, Jick H. Addiction rate in patients
  treated with narcotics. New Eng J Med 1980
  302 123.
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Risk Factors

• non-opioid substance abuse (OR 2.34)
• mental health disorder (OR 1.46)