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E LNE C End-of-Life Nursing Education Consortium International Curriculum Pain Management In Palliative Care E LNE C End-of-Life Nursing Education Consortium International Curriculum Pain Management In Palliative Care

Pain Is. . . • “An unpleasant sensory and emotional experience associated with actual Pain Is. . . • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage” IASP, 1979 • “What the person says it is…” Pasero & Mc. Caffery, 2011 E L N E C International Curriculum 2

Current Status of Pain • Cancer patients at end-of-life – 54% have pain • Current Status of Pain • Cancer patients at end-of-life – 54% have pain • AIDS with prognosis <6 months – intense pain APS, 2008; Paice, 2010 E L N E C International Curriculum 3

Current Status of Pain (cont. ) • Less research conducted in other chronic illness Current Status of Pain (cont. ) • Less research conducted in other chronic illness • Inadequate pain relief hastens death • Pain relief is essential at end of life E L N E C International Curriculum 4

Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. International Association for the Study of Pain E L N E C International Curriculum

Clinical Terms For The Sensory Disturbances Associated With Pain • Dysesthesia – An unpleasant Clinical Terms For The Sensory Disturbances Associated With Pain • Dysesthesia – An unpleasant abnormal sensation, whether spontaneous or evoked. • Allodynia – Pain due to a stimulus which does not normally provoke pain, such as pain caused by light touch to the skin • Hyperalgesia – An increased response to a stimulus which is normally painful • Hyperesthesia - Increased sensitivity to stimulation, excluding the special senses. Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms should be used wherever they are applicable. E L N E C International Curriculum

Approach To Pain Control in Palliative Care 1. Thorough assessment by skilled and knowledgeable Approach To Pain Control in Palliative Care 1. Thorough assessment by skilled and knowledgeable clinician – History – Physical Examination 2. Pause here - discuss with patient/family the goals of care, hopes, expectations, anticipated course of illness. This will influence consideration of investigations and interventions 3. Investigations – X-Ray, CT, MRI, etc - if they will affect approach to care 4. Treatments – pharmacological and nonpharmacological; interventional analgesia (e. g. . Spinal) 5. Ongoing reassessment and review of options, goals, expectations, etc. E L N E C International Curriculum

TYPES OF PAIN NOCICEPTIVE NEUROPATHIC Visceral Somatic • bones, joints • connective tissues • TYPES OF PAIN NOCICEPTIVE NEUROPATHIC Visceral Somatic • bones, joints • connective tissues • muscles • Organs – heart, liver, pancreas, gut, etc. Deafferentation E L N E C International Curriculum Sympathetic Maintained Peripheral

Somatic Pain • • Aching, often constant May be dull or sharp Often worse Somatic Pain • • Aching, often constant May be dull or sharp Often worse with movement Well localized Eg/ – Bone & soft tissue – chest wall E L N E C International Curriculum

Visceral Pain • • Constant or crampy Aching Poorly localized Referred Eg/ – CA Visceral Pain • • Constant or crampy Aching Poorly localized Referred Eg/ – CA pancreas – Liver capsule distension – Bowel obstruction E L N E C International Curriculum

FEATURES OF NEUROPATHIC PAIN COMPONENT Steady, Dysesthetic Paroxysmal, Neuralgic DESCRIPTORS • Burning, Tingling • FEATURES OF NEUROPATHIC PAIN COMPONENT Steady, Dysesthetic Paroxysmal, Neuralgic DESCRIPTORS • Burning, Tingling • Constant, Aching • Squeezing, Itching • Allodynia • Hypersthesia • Stabbing • Shock-like, electric • Shooting E L N E C International Curriculum • Lancinating EXAMPLES • Diabetic neuropathy • Post-herpetic neuropathy • trigeminal neuralgia • may be a component of any neuropathic pain

Pain Assessment E L N E C International Curriculum Pain Assessment E L N E C International Curriculum

“Describing pain only in terms of its intensity is like describing music only in “Describing pain only in terms of its intensity is like describing music only in terms of its loudness” von Baeyer CL; Pain Research and Management 11(3) 2006; p. 157 -162 E L N E C International Curriculum

PAIN HISTORY • Description: severity, quality, location, temporal features, frequency, aggravating & alleviating factors PAIN HISTORY • Description: severity, quality, location, temporal features, frequency, aggravating & alleviating factors • Previous history • Context: social, cultural, emotional, spiritual factors • Meaning • Interventions: what has been tried? E L N E C International Curriculum

Example Of A Numbered Scale E L N E C International Curriculum Example Of A Numbered Scale E L N E C International Curriculum

Medication(s) Taken • • • Dose Route Frequency Duration Efficacy Adverse effects E L Medication(s) Taken • • • Dose Route Frequency Duration Efficacy Adverse effects E L N E C International Curriculum

Physical Exam In Pain Assessment Inspection / Observation “You can observe a lot just Physical Exam In Pain Assessment Inspection / Observation “You can observe a lot just by watching” • Overall impression… the “gestalt”? Yogi Berra • Facial expression: Grimacing; furrowed brow; appears anxious; flat affect • Body position and spontaneous movement: there may be positioning to protect painful areas, limited movement due to pain • Diaphoresis – can be caused by pain • Areas of redness, swelling • Atrophied muscles • Gait • Myoclonus – possibly indicating opioid-induced neurotoxicity E L N E C International Curriculum

Physical Exam In Pain Assessment Palpation • Localized tenderness to pressure or percussion • Physical Exam In Pain Assessment Palpation • Localized tenderness to pressure or percussion • Fullness / mass • Induration / warmth E L N E C International Curriculum

Physical Exam In Pain Assessment Neurological Examination • Important in evaluating pain, due to Physical Exam In Pain Assessment Neurological Examination • Important in evaluating pain, due to the possibility of spinal cord compression, and nerve root or peripheral nerve lesions • Sensory examination – Areas of numbness / decreased sensation – Areas of increased sensitivity, such as allodynia or hyperalgesia • Motor (strength) exam - caution if bony metastases (may fracture) • Deep tendon reflexes – intensity, symmetry – Hyperreflexia and clonus: possible upper motor neuron lesion, such as spinal cord compression or cerebral metastases. – Hyoporeflexia - possible lower motor neuron impairment, including lesions of the cauda equina of the spinal cord or leptomeningeal metastases. • Sacral reflexes – diminished rectal tone and absent anal reflexes may indicate cauda equina involvement of by tumour E L N E C International Curriculum

Physical Exam In Pain Assessment Other Exam Considerations Further areas of focus of the Physical Exam In Pain Assessment Other Exam Considerations Further areas of focus of the physical examination are determined by the clinical presentation. Eg: evaluation of pleuritic chest pain would involve a detailed respiratory and chest wall examination. E L N E C International Curriculum

Pain Treatment E L N E C International Curriculum Pain Treatment E L N E C International Curriculum

Non-Pharmacological Pain Management • Acupuncture • Cognitive/behavioral therapy • Meditation/relaxation • Guided imagery • Non-Pharmacological Pain Management • Acupuncture • Cognitive/behavioral therapy • Meditation/relaxation • Guided imagery • TENS • Therapeutic massage • Others… E L N E C International Curriculum

W. H. O. ANALGESIC LADDER 3 By the Strong opioid +/- adjuvant 2 Clock W. H. O. ANALGESIC LADDER 3 By the Strong opioid +/- adjuvant 2 Clock es as Weak opioid +/- adjuvant ist rs 1 Non-opioid +/- adjuvant E L N E C International Curriculum or s ai P pe n re nc i

STRONG OPIOIDS • most commonly use: – morphine – Hydromorphone (Dilaudid ®) – transdermal STRONG OPIOIDS • most commonly use: – morphine – Hydromorphone (Dilaudid ®) – transdermal fentanyl (Duragesic®) – oxycodone – Methadone • DO NOT use meperidine (Demerolâ) long-term – active metabolite normeperidine ® seizu E L N E C International Curriculum

OPIOIDS and INCOMPLETE CROSS-TOLERANCE • conversion tables assume that tolerance to a specific opioid OPIOIDS and INCOMPLETE CROSS-TOLERANCE • conversion tables assume that tolerance to a specific opioid is fully “crossed over” to other opioids. • cross-tolerance unpredictable, especially in: – high doses – long-term use • divide calculated dose in ½ and titrate E L N E C International Curriculum

TITRATING OPIOIDS • dose increase depends on the situation • dose 25 - 100% TITRATING OPIOIDS • dose increase depends on the situation • dose 25 - 100% by EXAMPLE: (doses in mg q 4 h) E L N E C International Curriculum

http: //palliative. info E L N E C International Curriculum http: //palliative. info E L N E C International Curriculum

http: //palliative. info E L N E C International Curriculum http: //palliative. info E L N E C International Curriculum

E L N E C International Curriculum E L N E C International Curriculum

TOLERANCE PSYCHOLOGICAL DEPENDENCE / ADDICTION PHYSICAL DEPENDENCE E L N E C International Curriculum TOLERANCE PSYCHOLOGICAL DEPENDENCE / ADDICTION PHYSICAL DEPENDENCE E L N E C International Curriculum

TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the same effect Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4. 2. 3 E L N E C International Curriculum

PHYSICAL DEPENDENCE A normal physiological phenomenon in which a withdrawal syndrome occurs when an PHYSICAL DEPENDENCE A normal physiological phenomenon in which a withdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4. 2. 3 E L N E C International Curriculum

PSYCHOLOGICAL DEPENDENCE and ADDICTION A pattern of drug use characterized by a continued craving PSYCHOLOGICAL DEPENDENCE and ADDICTION A pattern of drug use characterized by a continued craving for an opioid which is manifest as compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drug Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4. 2. 3 E L N E C International Curriculum

Changing Route Of Administration In Chronic Opioid Dosing po / sublingual / rectal routes Changing Route Of Administration In Chronic Opioid Dosing po / sublingual / rectal routes reduce by ½ SQ / IV / IM routes E L N E C International Curriculum

Using Opioids for Breakthrough Pain • Patient must feel in control, empowered • Use Using Opioids for Breakthrough Pain • Patient must feel in control, empowered • Use aggressive dose and interval Patient Taking Short-Acting Opioids: • 50 - 100% of the q 4 h dose, given q 1 h prn Patient Taking Long-Acting Opioids: • 10 - 20% of total daily dose given, q 1 h prn with short-acting opioid preparation E L N E C International Curriculum

Opioid Side Effects • Constipation – need proactive laxative use • Nausea/vomiting – consider Opioid Side Effects • Constipation – need proactive laxative use • Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol) • Urinary retention • Itch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great success • Dry mouth • Respiratory depression – uncommon when titrated in response to symptom • Drug interactions • Neurotoxicity (OIN): delirium, myoclonus ® seizures E L N E C International Curriculum

E L N E C International Curriculum E L N E C International Curriculum

Spectrum of Opioid-Induced Neurotoxicity Opioid tolerance Mild myoclonus (eg. with sleeping) Delirium Opioids Increased Spectrum of Opioid-Induced Neurotoxicity Opioid tolerance Mild myoclonus (eg. with sleeping) Delirium Opioids Increased Severe myoclonus Seizures, Death Hyperalgesia Agitation Misinterpreted as Pain E L N E C International Curriculum Opioids Increased Misinterpreted as Disease-Related Pain

OIN: Treatment • Switch opioid (rotation) or reduce opioid dose; usually much lower than OIN: Treatment • Switch opioid (rotation) or reduce opioid dose; usually much lower than expected doses of alternate opioid required… often use prn initially • Hydration • Benzodiazepines for neuromuscular excitation E L N E C International Curriculum

Adjuvant Analgesics • first developed for non-analgesic indications • subsequently found to have analgesic Adjuvant Analgesics • first developed for non-analgesic indications • subsequently found to have analgesic activity in specific pain scenarios • Common uses: – pain poorly-responsive to opioids (eg. neuropathic pain), or – with intentions of lowering the total opioid dose and thereby mitigate opioid side effects. E L N E C International Curriculum

Adjuvants Used In Palliative Care • General / Non-specific – corticosteroids – cannabinoids (not Adjuvants Used In Palliative Care • General / Non-specific – corticosteroids – cannabinoids (not yet commonly used for pain) • Neuropathic Pain – gabapentin – antidepressants – ketamine – topiramate – clonidine • Bone Pain – bisphonates – (calcitonin) E L N E C International Curriculum

CORTICOSTEROIDS AS ADJUVA · ¯ inflammation · ¯ edema } ¯ tumor mass effects CORTICOSTEROIDS AS ADJUVA · ¯ inflammation · ¯ edema } ¯ tumor mass effects · ¯ spontaneous nerve depolarization E L N E C International Curriculum

CORTICOSTEROIDS: ADVERSE EFFECTS IMMEDIATE • Psychiatric • Hyperglycemia LONG-TERM • • • risk of CORTICOSTEROIDS: ADVERSE EFFECTS IMMEDIATE • Psychiatric • Hyperglycemia LONG-TERM • • • risk of GI bleed Ø gastritis • Ø aggravation of existing • lesion (ulcer, tumor) • Immunosuppression E L N E C International Curriculum Proximal myopathy often < 15 days Cushing’s syndrome Osteoporosis Aseptic / avascular necrosis of bone

DEXAMETHASONE • minimal mineralcorticoid effects • po/iv/sq/? sublingual routes • perhaps can be given DEXAMETHASONE • minimal mineralcorticoid effects • po/iv/sq/? sublingual routes • perhaps can be given once/day; often given more frequently • If an acute course is discontinued within 2 wks, adrenal suppression not likely E L N E C International Curriculum

Treatment of Neuropathic Pain Pharmacologic treatment • Opioids • Steroids • Anticonvulsants – gabapentin, Treatment of Neuropathic Pain Pharmacologic treatment • Opioids • Steroids • Anticonvulsants – gabapentin, topiramate • TCAs (for dysesthetic pain, esp. if depression) • NMDA receptor antagonists: ketamine, methadone • Anesthetics Radiation therapy Interventional treatment • Spinal analgesia • Nerve blocks E L N E C International Curriculum

Gabapentin • Common Starting Regimen – 300 mg hs Day 1, 300 mg bid Gabapentin • Common Starting Regimen – 300 mg hs Day 1, 300 mg bid Day 2, 300 mg tid Day 3, then gradually titrate to effect up to 1200 mg tid • Frail patients – 100 mg hs Day 1, 100 mg bid Day 2, 100 mg tid Day 3, then gradually titrate to effect E L N E C International Curriculum

Incident Pain occurring as a direct and immediate consequence of a movement or activity Incident Pain occurring as a direct and immediate consequence of a movement or activity E L N E C International Curriculum

Circumstances In Which Incident Pain Often Occurs • Bone metastases • Neuropathic pain • Circumstances In Which Incident Pain Often Occurs • Bone metastases • Neuropathic pain • Intra-abd. disease aggravated by respiration » “incident” = breathing » ruptured viscus, peritonitis, liver hemorrhage • Skin ulcer: dressing change, debridement • Disimpaction • Catheterization E L N E C International Curriculum

Having a steady level of enough opioid to treat the peaks of incident pain. Having a steady level of enough opioid to treat the peaks of incident pain. . . Pain . . . would result in excessive dosing for the periods between incidents Incident Time E L N E C International Curriculum Incident

Fentanyl and Sufentanil § synthetic µ agonist opioids § highly lipid soluble • transmucosal Fentanyl and Sufentanil § synthetic µ agonist opioids § highly lipid soluble • transmucosal absorption; effect in approx 10 min • rapid redistribution, including in / out of CSF; lasts approx 1 hr. § fentanyl » 100 x stronger than morphine § sufentanil » 1000 x stronger than morphine 10 mg morphine » 10 µg sufentanil » 100 µg fentanyl E L N E C International Curriculum

INCIDENT PAIN PROTOCOL (see also http: //palliative. info) Step Medication # (50 mg/ml) # INCIDENT PAIN PROTOCOL (see also http: //palliative. info) Step Medication # (50 mg/ml) # Micrograms Sublingually 1 Fentanyl 50 2 Sufentanil 25 3 Sufentanil 50 4 Sufentanil 100 E L N E C International Curriculum

INCIDENT PAIN PROTOCOL ctd. . . • fentanyl or sufentanil is administered SL 10 INCIDENT PAIN PROTOCOL ctd. . . • fentanyl or sufentanil is administered SL 10 min. prior to anticipated activity • repeat q 10 min x 2 additional doses if needed • increase to next step if 3 total doses not effective • physician order required to increase to next step if within an hour of last dose • the Incident Pain Protocol may be used up to q 1 h prn E L N E C International Curriculum

Barriers to Pain Relief • Importance of discussing barriers • Specific barriers – Professionals Barriers to Pain Relief • Importance of discussing barriers • Specific barriers – Professionals – Health care systems – Patients/families Miaskowski et al. , 2005; Paice, 2010; Pasero & Mc. Caffery, 2011 E L N E C International Curriculum 55

Pain Assessment • Pain history • Pain terms • Acute vs. chronic Fink & Pain Assessment • Pain history • Pain terms • Acute vs. chronic Fink & Gates, 2010 E L N E C International Curriculum 56

Pain History • • Location Intensity Quality Temporal pattern E L N E C Pain History • • Location Intensity Quality Temporal pattern E L N E C International Curriculum 57

Pain History • • Aggravating/alleviating factors Medication history (recent and distant) Meaning of pain Pain History • • Aggravating/alleviating factors Medication history (recent and distant) Meaning of pain Cultural factors E L N E C International Curriculum 58

Physical Examination • • Observation Palpation Auscultation Percussion E L N E C International Physical Examination • • Observation Palpation Auscultation Percussion E L N E C International Curriculum 59

Functional Assessment • Ability to dress self • Walking • Cooking E L N Functional Assessment • Ability to dress self • Walking • Cooking E L N E C International Curriculum 60

Laboratory/Diagnostic Evaluation • Rule out potentially treatable causes • Need for additional laboratory or Laboratory/Diagnostic Evaluation • Rule out potentially treatable causes • Need for additional laboratory or radiographic evaluation is directed by the goals of care E L N E C International Curriculum 61

Reassess • Changes in pain • Assess pain relief • Make pain visible E Reassess • Changes in pain • Assess pain relief • Make pain visible E L N E C International Curriculum 62

Common Syndromes at the End of Life • Nociceptive – Somatic – Visceral • Common Syndromes at the End of Life • Nociceptive – Somatic – Visceral • Neuropathic – – Post herpetic neuropathy Diabetic neuropathy HIV associated neuropathy Chemotherapy related neuropathy E L N E C International Curriculum 63

Pain vs. Suffering at the End of Life • Existential distress • Dimensions of Pain vs. Suffering at the End of Life • Existential distress • Dimensions of quality of life • Requires interdisciplinary approach E L N E C International Curriculum 64

Patients at Risk for Undertreatment • • Children and older adults Non-verbal or cognitively Patients at Risk for Undertreatment • • Children and older adults Non-verbal or cognitively impaired Patients who deny pain Patients who speak a different language • Different cultures • History of addictive disease E L N E C International Curriculum 65

Communicating Assessment Findings • Communication improves pain management • Describe intensity, limitations, and response Communicating Assessment Findings • Communication improves pain management • Describe intensity, limitations, and response to treatments • Documentation Gordon et al, 2005; Pasero & Mc. Caffery, 2011 E L N E C International Curriculum 66

Definitions • • Tolerance Physiologic dependence Psychological dependence Opioids and death E L N Definitions • • Tolerance Physiologic dependence Psychological dependence Opioids and death E L N E C International Curriculum 67

Pharmacological Therapies • Nonopioids • Opioids • Adjuvants APS, 2008; Pasero & Mc. Caffery, Pharmacological Therapies • Nonopioids • Opioids • Adjuvants APS, 2008; Pasero & Mc. Caffery, 2011 E L N E C International Curriculum 68

Nonopioids • Paracetamol • NSAIDs APS, 2008; Paice, 2010: Pasero & Mc. Caffery, 2011 Nonopioids • Paracetamol • NSAIDs APS, 2008; Paice, 2010: Pasero & Mc. Caffery, 2011 E L N E C International Curriculum 69

Nonopioids: NSAIDs Adverse Effects E L N E C International Curriculum 70 Nonopioids: NSAIDs Adverse Effects E L N E C International Curriculum 70

Opioids • • • Morphine Codeine Fentanyl Tramadol Methadone Pethidine E L N E Opioids • • • Morphine Codeine Fentanyl Tramadol Methadone Pethidine E L N E C International Curriculum 71

Opioids: Adverse Effects • • • Respiratory depression Constipation Sedation Urinary retention Nausea/vomiting Pruritus Opioids: Adverse Effects • • • Respiratory depression Constipation Sedation Urinary retention Nausea/vomiting Pruritus E L N E C International Curriculum 72

Adjuvant analgesics • • Antidepressants Anticonvulsants Local anesthetics Corticosteroids E L N E C Adjuvant analgesics • • Antidepressants Anticonvulsants Local anesthetics Corticosteroids E L N E C International Curriculum 73

Antidepressants • Block serotonin and norepinephrine • Administer at bedtime • Side effects • Antidepressants • Block serotonin and norepinephrine • Administer at bedtime • Side effects • SSRIs have little analgesic effect • Newer agents E L N E C International Curriculum 74

Anticonvulsants/Antiepilepsy Drugs • Older agents have significant adverse effects • Newer agents: – Gabapentin Anticonvulsants/Antiepilepsy Drugs • Older agents have significant adverse effects • Newer agents: – Gabapentin – Pregabalin – Lamotrigine, levetiracetam, oxcarbazepine and others E L N E C International Curriculum 75

Local Anesthetics • Topical: Lidocaine gel or patch (plaster) • Intravenous • Spinal E Local Anesthetics • Topical: Lidocaine gel or patch (plaster) • Intravenous • Spinal E L N E C International Curriculum 76

Corticosteroids • Dexamethasone has least mineralocorticoid effect • Psychosis • Proximal muscle wasting • Corticosteroids • Dexamethasone has least mineralocorticoid effect • Psychosis • Proximal muscle wasting • Administer - q am E L N E C International Curriculum 77

Routes of Administration • • • Oral Mucosal Rectal Transdermal Topical E L N Routes of Administration • • • Oral Mucosal Rectal Transdermal Topical E L N E C International Curriculum 78

Routes of Administration (cont. ) • Parenteral – Intravenous – Subcutaneous – Intramuscular E Routes of Administration (cont. ) • Parenteral – Intravenous – Subcutaneous – Intramuscular E L N E C International Curriculum 79

Routes of Administration (cont. ) • Spinal – Epidural – Intrathecal E L N Routes of Administration (cont. ) • Spinal – Epidural – Intrathecal E L N E C International Curriculum 80

WHO 3 Step Analgesic Ladder Pain Management Step 1: Mild pain Step 2: Moderate WHO 3 Step Analgesic Ladder Pain Management Step 1: Mild pain Step 2: Moderate pain Step 3: Severe pain E L N E C International Curriculum 81

Principles: Prevent and Treat Side Effects • Anticipate • Prevent • Treat E L Principles: Prevent and Treat Side Effects • Anticipate • Prevent • Treat E L N E C International Curriculum 82

Principles: Long Acting Medications • Sustained release medications • Immediate release for breakthrough pain Principles: Long Acting Medications • Sustained release medications • Immediate release for breakthrough pain • Distinguish types of breakthrough pain –Episodic –Idiopathic –End of dose failure E L N E C International Curriculum 83

Principles of Equianalgesia • Determine equal doses when changing drugs or routes of administration Principles of Equianalgesia • Determine equal doses when changing drugs or routes of administration • Oral to parenteral morphine 3: 1 ratio • Reduce by 25% when changing drugs • Use of morphine equivalents E L N E C International Curriculum 84

Principles: Use of Opioid Rotation • Use when one opioid is ineffective even with Principles: Use of Opioid Rotation • Use when one opioid is ineffective even with adequate titration • Use when adverse effects are unmanageable E L N E C International Curriculum 85

Placebos • Not diagnostic • Causes mistrust • Never ethical E L N E Placebos • Not diagnostic • Causes mistrust • Never ethical E L N E C International Curriculum 86

Cancer Therapies to Relieve Pain • • • Radiation Surgery Chemotherapy Hormonal therapy Others Cancer Therapies to Relieve Pain • • • Radiation Surgery Chemotherapy Hormonal therapy Others Doyle et al. , 2001; Janjan et al. , 2003; Jeremic, 2001 E L N E C International Curriculum 87

Interventional Therapies • Neurolytic blocks • Neuroablative procedures • Vertebroplasty Furlan et al. , Interventional Therapies • Neurolytic blocks • Neuroablative procedures • Vertebroplasty Furlan et al. , 2001; Mathias et al. , 2001; Swarm et al. , 2010 E L N E C International Curriculum 88

Non-Pharmacologic Techniques • Cognitive - behavioral therapies – Relaxation – Imagery – Distraction – Non-Pharmacologic Techniques • Cognitive - behavioral therapies – Relaxation – Imagery – Distraction – Support groups – Pastoral counseling E L N E C International Curriculum 89

Non-Pharmacologic Techniques (cont. ) • Physical measures (heat, cold, massage) • Complementary therapies • Non-Pharmacologic Techniques (cont. ) • Physical measures (heat, cold, massage) • Complementary therapies • Repositioning/ bracing Ernst, 2004; Kravits & Berenson, 2010; Smith et al. , 2002 E L N E C International Curriculum 90

Pain in HIV • • • Abdominal pain Headache Musculosketal pain Neuropathy Oral lesions Pain in HIV • • • Abdominal pain Headache Musculosketal pain Neuropathy Oral lesions E L N E C International Curriculum 91

Roles of the Healthcare Team • • Direct clinical care Patient/family teaching Education of Roles of the Healthcare Team • • Direct clinical care Patient/family teaching Education of colleagues Identify system barriers a work to correct E L N E C International Curriculum 92

Conclusion • Pain relief is contingent on adequate assessment and use of both drug Conclusion • Pain relief is contingent on adequate assessment and use of both drug and non-drug therapies • Pain extends beyond physical causes to other causes of suffering and existential distress • Interdisciplinary care E L N E C International Curriculum 93

Freedom 94 Freedom 94

Give the answers to the following questions please: 1. The definitions of Dysesthesia, Allodynia, Give the answers to the following questions please: 1. The definitions of Dysesthesia, Allodynia, Hyperalgesia, Hyperesthesia 2. Compare the nociceptive and neuropathic pain. What are the difference? 3. What are the main opioids used in palliative care? E L N E C International Curriculum