PALLIATIVE CARE

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PALLIATIVE CARE

• Stephen A. Bernard, M.D.
• University of North Carolina

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Palliative Care

• Pain Management
• Nausea and vomiting
• Dyspnea
• Constipation
• Cachexia
• Skin problems

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Pathophysiology of Chronic Pain

• Type of Pain
• Nociceptive
• Visceral
• Neuropathic
• Complex RegionalPain Syndromes

• Mechanism
• Nociceptors
• Nociceptors
• Ectopic discharges
• Sensitization of spinalneurons

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Nociceptors

• Escalating response to repetitive stimuli
• Not spontaneously active
• Sensitization of nociceptors occurs quickly
• Results in hyperalgesia
• Mediated by efferent sympathetic activity
• Mediated by chemical substances

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Nociceptive fibers

• A delta--thinly myelinated, 10 carry nociceptive
  traffic, mechanical activation
• C--unmyelinated, 90 are nociceptive, polymodal
• Silent nociceptive fibers, active with injury

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Neuropathic pain

• Results from injury
• Described as lancinating, or burning
• May be seen in cancer patients after surgery,
  radiation, or chemotherapy
• May coexist with other types of pain

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Visceral pain

• Differs from cutaneous nociceptive pain
• May be referred
• Not activated by cutting of an organ
• Pain is deep and aching

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Sympathetic Nervous System, Role in Chronic Pain

• May be involved in neuropathic and visceral pain
• Increased sensitivity to sympathetic stimulation
• Complex regional pain syndrome?

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Pain Management

• Definition of acute,chronic pain
• Epidemiology of cancer pain
• Pathophysiology, new Am Soc Clin Oncol
  Guidelines/classification
• WHO guidelines
• AHCPR principles of acute pain management

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AHCPR Guidelines-Acute Pain

• 1. Promise patients attentive analgesic care
• 2. Chart assessment of pain and relief
• 3. Define pain and relief levels--trigger point
• 4. Survey patient satisfaction
• 5. Analgesic drug treatment--std principles
• 6. Use of specialized techniques
• 7. Nonpharmacologic interventions
• 8. Monitor efficacy of pain management

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International Barriers

• Lack of infrastructure
• Inadequate education
• Legislative restrictions
• Lack of oral opioids
• High cost
• Uneven distribution

Source Cancer Pain Release, 1996
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AHCPR Guidelines--Chronic Pain

• Reassurance of pain relief
• Provide relief
• Educational curricula should include pain
  management
• Educate patient/family--actively involved
• Regulatory restrictions
• Collaboration with patient and family

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Issues in Pain Management

• Role of prior experience
• Attitudes about the meaning of pain
• Relation of pain to prognosis
• Risk of addiction/overdosage
• Regulatory issues
• Ethical issues
• Malpractice concerns

Jour. Cancer Educ., 1996
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Tolerance

• Rare, more often due to disease progression
• Physical dependence, common, requires taper
• Addiction or psychological dependence uncommon

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Use of the WHO Ladder

• Use of step one, non-opioids, rarely effective in
  cancer pain
• Step two drugs limited, codeine side effects
  increase above 1.5 mg./kg
• Use of step three drugs may offer the best
  control

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Individual Agents

• Morphine has a variety of preparations
• Oxycodone can be given without acetaminophen and
  titrated to much higher doses
• Hydromorphone can be given at much small volumes
• Fentanyl can be used for stable patients unable
  to tolerate oral drugs

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THE IDEAL DOSE

• Significant reduction of pain the goal
• Respiratory depression can occur, but doses as
  high as 4500 mg/hour have been given without
  problems
• Sedation is more often dose limiting

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Route of Administration

• Oral
• Buccal
• Intradermal/Subcutaneous
• Intravenous
• Epidural
• Intrathecal/intraventricular
• Rectal

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Breakthrough Pain

• Combination of short acting and long acting drug
• Frequent use of short acting drug means dose or
  interval of long acting drug needs adjustment
• Use of adjuvant drugs for selected clinical
  situations may avoid need to increase dose of
  narcotic

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Recommendations

• Believe the patient
• Tolerance is seldom an issue
• Start with a drug which has a reasonable chance
  of success and titrate upwards every 24-48 hours
• Look for other causes of pain also

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Newer Adjuvants

• Muscle relaxants--baclofen
• Strontium
• Biphosphonates, calcitonin--may decrease pain in
  20-50 of patients
• Myoclonic jerking seen with morphine--may be
  relieved with clonazepam

Adapted from Levy, NEJM, 1996
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Morphine Metabolites

• Oral doses undergo conversion by glucuronyl
  transferase in liver
• Principal metabolite-- 3 beta glucuronide,
  accounts for 50 of dose
• 6 beta glucuronide accounts for 5 of dose but
  may play a greater role in analgesic effect

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DEMEROL
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Demerol

• Large oral doses to give equianalgesic effect
• Potential for buildup of CNS excitatory
  metabolites--normeperidine
• May occur even with normal renal function
• Seizure potential increases with cumulative doses
  of 900-1,000 mg in 24 hours