Title: The Mary Stevens Hospice Stourbridge
1The Mary Stevens Hospice Stourbridge
- Lucy Martin - Medical Director
- (BCVTS 1997 2000!)
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3VTS March 4th 2010
- 1.30 Session on Palliative Care and Basics of
Pain Control, plus discussion and questions - 2.45 Coffee / Tea
- 3.00 Case discussion 1 feedback
- 3.45 Case discussion 2 feedback
- 4.30 Plenary and close
4What is Palliative Care?
5WHO Definition
- Palliative care is an approach that improves the
quality of life of patients and their families
facing the problem associated with
life-threatening illness, through the prevention
and relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual.
6- provides relief from pain and other distressing
symptoms - affirms life and regards dying as a normal
process - intends neither to hasten or postpone death
- integrates the psychological and spiritual
aspects of patient care - offers a support system to help patients live as
actively as possible until death - offers a support system to help the family cope
during the patient's illness and in their own
bereavement
7- uses a team approach to address the needs of
patients and their families, including
bereavement counselling, if indicated - will enhance quality of life, and may also
positively influence the course of an illness - is applicable early in the course of illness, in
conjunction with other therapies that are
intended to prolong life, such as chemotherapy or
radiation therapy, and includes those
investigations needed to better understand and
manage distressing clinical complications.
8Who provides Palliative Care?
9- Generalist
- GPs, District Nurses, Hospitals
- Providing day-to-day care in hospital or patients
home - Specialist
- Palliative Care Teams based in hospices,
hospitals, community - Multidisciplinary Core members are doctors
nurses, AHPs - In-patient and Day care facilities, hospice at
home - Ongoing advice and support in any setting
- Bereavement support
- Education and training for specialists and
generalists
10Day care since 1993, and residential since
1999Referral form _at_ www.marystevenshospice.co.uk
11Specialist Palliative Care in Dudley
- Hospice in-patient care / day care
- Mary Stevens covers the whole Dudley borough
- Hospital in-patient care
- no dedicated hospital beds
- 0.4 WTE consultant out pt and consultation
- hospital palliative care team MDT meeting
- Community Service
- Macmillan CNS and OT / Physio team
- Palliative Care end of life team
12- What you know about pain management?
- What do you feel confident about?
- What makes you nervous?
13- WHO ladder / lift
- Cancer and non-cancer chronic pain
- Dudley Pain Management Guidelines
14Principles of analgesic use
- By the mouth
- By the clock
- By the ladder
- Refers to WHO analgesic ladder
- Treatment should be individualised
- Use adjuvants
- Drugs for specific situations e.g. Neuropathy
- Drugs to control side effects
- Psychotropics
- Twycross, R Introducing Palliative Care,
Symptom management of advanced cancer
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16Strong opioids
- Should be given according to need and response
- Should not be given according to prognosis
- Administration still surrounded by concern
17- Little clinically significant respiratory
depression, tolerance not a problem, dependence
does not occur - Naloxone very rare
- Patients generally have been receiving weak
opiates first - Dose gets titrated start low, go slow
- Pain is an antagonist to central depressant
effects of strong opiates - Therapeutic dose vs. toxic / lethal dose
18Opioids in the well person (or How I did it by
H. Shipman)
19Opioids in Cancer Pain (and probably non-cancer
pain too)
20Morphine
- 200 years of experience
- Cheap
- 4 formulations IR elixir and tablet, SR liquid
and tablet / capsule - Flexibility in dosing, multiple strengths
available, flexible routes - Predictable titration schedule
- Metabolites accumulate in brain and CSF if renal
dysfunction - 20 30 population do not tolerate
21Equivalent Doses
- Equivalent 24hr Morphine Dose
- Morphine 25mg
- Morphine 25mg
- Morphine 25mg
- Morphine 40 - 80mg
- Morphine 60mg
- Morphine 7.5mg p.o. every 30 mins
- Codeine 60mg qds p.o.
- Dihydrocodeine 60mg qds p.o.
- Pethidine 50mg qds p.o.
- Tramadol 100mg qds p.o.
- Fentanyl 25mcg t.d.
- Diamorphine 2.5mg s.c. every 30 mins
22Titrating in the community
- Easiest method is the 4-hourly plus rescue
- Calculate current morphine equivalent / 24hr
- /- make allowance for uncontrolled pain
- Divide by 6
- 4 hourly dose / rescue dose
- 2 3 days record
- Review, then divide and convert to sustained
release prep, plus rescue (1/6th of total daily
dose)
23Increasing doses of opioid
- Gradual escalation of doses if pain control
inadequate - Dose escalations of less than 30 50 are
unlikely to have much effect - Experience shows 30 50 dose increases are safe
- Absolute dose is immaterial as long as balance
between analgesia / side effects - Less is known about titration for dyspnea
24Why / when to switch opioid
- Intolerable side effects
- Itching, neurotoxicity, that persist despite
appropriate intervention - Lack of desired analgesic effect
- Even with rapidly escalating doses
- Moderate or severe renal disease
- Egfr lt60 ??
- Alternative route is required
- Unstable pain on a patch
- Patients personal choice / opiophobia
25Diamorphine
- Cheap
- May work via receptors other than µ - explaining
the apparent differences with morphine - More soluble / lipophilic than morphine
parenteral use /small volumes - Quicker action, less vomiting
- Not useful orally
- More sedating than morphine
- Fear / preconceptions of patients and HCPs
26Oxycodone
- Potent drug orally
- Flexibility in SR dose formulations
- Effective levels within 1 hour good for
titration - Rectal formulation
- Metabolites not part of the analgesic picture
- Possibility of neuropathic effect
- Differing views in different countries USA see
it as a step 2 drug - Common drug of abuse in USA
27Hydromorphone (palladone)
- Multiple routes of admin oral, parenteral,
rectal and intraspinal - Very soluble good for subcut use
- Oral dosing complicated and oral breakthrough
dose multiple capsules - Difficulty predicting dose equivalency with
morphine
28Fentanyl alfentanil
- Transdermal delivery due to lipophilic nature
- Intravenous rapid onset of action
- Buccal / sublingual / intranasal immediate
release formulation - Convenience / compliance
- Possibly less constipation
- Delay of effective analgesia 8 -12 hrs initially
- Poor dosing flexibility
- Uncertainty with BMI
- Cost
- Contraindication in uncontrolled pain due to
titration period - Patch adhesion problems
29Methadone
- Potent orally
- Useful in pain with neurological components
- Unpredictable accumulation / plasma concentration
rises over long periods unpredictable side
effects - Steady state 1 week
- Not really practical in community setting
30Please dont forget
- Constipation
- senna/ lactulose
- movicol
- co-danthrusate / co-danthramer
- Nausea
- metoclopramide / domperidone
- haloperidol
31Where to look for information?
- Twycross books are the bibles
- Palliative Care Formulary 3rd Edition
- Symptom management of advanced cancer - 4th
Edition - Introducing Palliative Care
- Palliativedrugs.com online version of PCF
- More detail
- Oxford Textbook of Palliative Medicine
- West Midlands pain handbook
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