DR HANNAH GUNN

CONSULTANT IN PALLIATIVE MEDICINE

NORTHUMBRIA HEALTHCARE & MARIE CURIE HOSPICE NEWCASTLE

Analgesic Trade Secrets

Session Outline

Defining painTypes of pain

Noceceptive Neuropathic Total

WHO Analgesic LadderAdjuvants

Case histories

Defining Pain

What is pain?

What is pain?

• Pain is 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 (IASP) 1986

What is pain?

• Pain is 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 (IASP) 1986

Pain is what the patient says hurts

Types of Pain

Types of Pain

Nociceptive Pain Neuropathic Pain

Types of Pain

Nociceptive Pain Transmitted by

undamaged nervous system

Opioid receptors involved

Impulse spinal cord higher centres

WHO analgesic ladder

Neuropathic Pain Transmitted by

damaged nervous system

Partial opioid sensitive Associated with

hyperalgesia and allodynia

WHO analgesic ladder Adjuvants

Total Pain

Total Pain

Total Pain

Pain Management Strategy

Pain Management Strategy

Modify pathological process

Surgery Radiotherapy Chemotherapy

Choose an analgesic WHO analgesic

ladder Adjuvants Side effects

Non-drug management of pain

Address all the domains of total pain

Heat pads, TENS

Lifestyle modification

Home equipment Walking aides Care package

WHO analgesic ladder

Choice of drug based on severity of pain NOT on stage of disease

Adjuvants

When is an analgesic not an analgesic?

When it’s an adjuvant!Anti-

epileptic

Anti-depressant

Anti-

spasmodi

c

Muscle relaxants

Steroid

Bisphosphonate

Ketamine

Methadone

Choice of drug based on severity of pain NOT on stage of disease

Common Adjuvants

Raised intracranial pressure

CorticosteroidsNerve compression

Liver capsule pain

Soft tissue infiltration

Neuropathic pain(including tenesmoid pain)

Anti-depressants (eg amitriptyline) & Anti-convulsants ( eg. Gabapentin)

Colic Antispasmodic ( eg buscopan)

Muscle cramp/spasm Muscle relaxants (eg baclofen)

Bone pain Bisphosphonates

Case 1

Joan, 63 year old womanDiagnosed with left breast cancer 2 years ago

Mastectomy Radiotherapy and chemotherapy Ongoing hormone therapy

Presents to GP with RUQ pain, worse on inspiration, ‘like I’ve pulled a muscle’

Some vomiting, especially later in day, large volumes, hiccoughs and belching

Liver Capsule Pain

Aetiology Liver metastases

Presentation RUQ pain Stretch quality Can vary with respiration

Management Dexamethasone 8-16mg mane with PPi cover

Case 2

Brian, 74 year old man8 year history of prostate cancerAdmitted with severe lower back pain,

increasing for last few weeks, now unable to walk due to pain

SPINAL CORD COMPRESSIO

N

Bone Pain

Aetiology Bone infiltration Pathological fractures

Presentation Severe pain Associated with site of metastases

Management WHO analgesic ladder Adjuvant analgesics

Dexamethasome 8-16mg mane with PPi cover Bisphosphonate infusion Gabapentin or amitriptyline

Paracetamol and NSAID

and morphine

Summary

Pain is what the patient says hurtsWHO analgesic ladderAdjuvantsReview, review, review

Pain is what the patient says hurtsWHO analgesic ladderAdjuvantsReview, review, review

Ask your friendly neighbourhood palliative care team!

Thank You!

HannahGunn@nhs.net