DISTRESSING SYMPTOMS

Symptoms that contribute to the

suffering of a terminally ill patient

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 DISTRESSING SYMPTOMS

General GIT CNS Skin Resp

• Pain • Nausea and • Depression • Itch • Dyspnoea

• Fatigue vomiting • Delirium • Pressure • Cough
• Diarrhoea • Raised sores • Hiccup
• Constipation intracranial • Excessive
• Swallowing pressure secretions
difficulties • Convulsion
• insomnia

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PAIN

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 DEFINITION OF PAIN:

 The International Association for the Study of Pain (IASP)

defines pain as: An unpleasant sensory and emotional
experience, associated with actual or potential tissue
damage.

• Respect the patient on what he/she says he/she is

experiencing.
• Each patient experiences and expresses pain
differently.

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 PAIN
• Is PAIN a
Symptom

OR
Sign

SIGN
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 PAIN-history
• CHARACTERISTICS OF PAIN (SOCRATES)
• Site
• Onset
• Character
• Radiation
• Associated symptoms
• Timing duration, course, pattern
• Exacerbating and relieving factors
• Severity

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 CLASSIFICATION OF PAIN

nociceptive neuropathic inflammatory cancer pain

Chronic pain Incident pain

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 CLASSIFICATION OF PAIN

nociceptive neuropathic inflammatory cancer pain

normal response to Caused by primary Activation and Tu presses on

noxious lesion dx in the sensitization of bones, nerves, body
somatosensory nociceptive pain organs
1.Somatic-well nervous system pathway by a
localised e.g.. variety of mediators radiation
e.g.. MSK, cutaneous 1.diabetes PN release at sites of
inflammation
2.Post herpetic e.g.. Appendicitis
2. Visceral-vague
neuralgia RA
e.g.. hollow organs,
IBD
referred pain
3.Phantom limb

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 MEASUREMENT OF PAIN
 Verbal rating/descriptor scale: Different verbal descriptions
are used to rate pain
'no pain', 'mild pain', 'moderate pain' and 'severe pain'.
 Numerical rating scale-11-point scale: A question is used,
such as 'Over the past 24 hours, how would you rate your
pain?
if 0 is no pain and 10 is the worst pain you could imagine?’
 Visual analogue scale: Mark on the line below how strong
your pain is
No pain<------------------------------------------------------->Worst pain

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 faces

visual

numerical

verbal

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 PAIN-history
• INDIVIDUAL ASPECTS-RICEFF
• Reason for encounter
• Ideas
• Concerns
• Expectations
• Fears
• Feelings
• Impact of activities of daily living

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 PAIN-examination

look Inspection

Palpation
feel
Percussion

move Auscultation

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 PAIN…
 Document all your findings
 Communicate with patient
 Review regularly

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 APPROPRIATE INVESTIGATIONS
 Investigations should be directed towards diagnosis of an
underlying cause, remembering that reversible causes are
possible even in patients with life threating diseases

 Imaging may be indicated, such as plain X-ray for

fracture

 Magnetic resonance imaging (MRI) for spinal cord

compression

 Bone scan for metastasis

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 MANAGEMENT OF PAIN
Pharmacological Treatments
• The WHO Analgesic Ladder
 The basic principle of the WHO ladder is that analgesia
which is appropriate for the degree of pain should be
prescribed and the dose increased until pain is
controlled
 If pain is severe or remains poorly controlled, strong
opioids should be prescribed.
 Never move Laterally on the Analgesic Ladder, go
upwards and you may skip steps when starting
medication depending on severity of the pain.
 Don’t give a weak opioid with a strong opioid

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 NON-OPIOIDS

 Paracetamol. This is often effective for mild to moderate pain. For

severe pain, it is inadequate alone, but remains a useful and well-
tolerated adjunct.

 NSAIDs. These are effective in the treatment of mild to moderate

pain, and are also useful adjuncts in the treatment of severe pain.
Adverse effects may be serious, especially in the elderly

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 WEAK OPIOIDS

 Codeine and dihydrocodeine are weak opioids

 They have lower analgesic efficacy than strong opioids

 They are effective for mild to moderate pain

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 STRONG OPIOIDS

 MORPHINE
 Never combine a weak with a strong opioids
 Immediate-release (IR) oral morphine takes about 20 minutes to have
an effect and usually provides pain relief for 4 hours. Can be in Tablet
form or Syrup.
 Most patients with continuous pain should be prescribed IR oral
morphine every 4 hours (i.e. six times daily) initially, which will
provide continuous pain relief over the whole 24-hour period.
 Controlled-release (CR) morphine lasts for 12 or 24 hours but takes
much longer to take effect. It should only be used once the correct
dose has been found through dose titration with IR morphine until
adequate is achieved

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 STRONG OPIOIDS

 'breakthrough' pain give extra doses

 The regular 24-hour dose should then be increased by adding on the total of the
breakthrough doses over the previous 24 hours, unless there are significant
problems with unacceptable side-effects

 When the correct dose has been established, a CR preparation can be prescribed,
usually twice daily

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BREAKTHROUGH PAIN

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 MANAGEMENT OF PAIN
Pharmacological Treatments

 The gold standard of the WHO (1982) for treating cancer pain is the use of
Morphine, administered
 By Mouth
The oral route is preferred for all steps of the pain
ladder
 By the Clock
Cancer pain is continuous - analgesics should be
given at regular intervals (every three to six hours),
not on demand
 By the Ladder 30
 ADJUVANT ANALGESICS
Drug Dosage
50 mg oral 8-hourly (SR 75 mg
12-hourly)
NSAIDs (e.g. diclofenac)
100mg per rectum once a day
8-16 mg per day (titrate down
Corticosteroids (e.g.
to lowest dose which controls
dexamethasone)
pain)
100-300 mg nocte (starting
Gabapentin dose; titrate to 600 mg 8-
hourly)
Carbamazepine (evidence for 100-200 mg nocte (starting
all anticonvulsants) dose)
24 mg nocte (starting dose)
Amitriptyline (evidence for all
tricyclics)
10 mg (elderly)
Ketamine 10-60 mg 6-hourly
Indications
Bone metastases, soft tissue
infiltration, liver pain,
inflammatory pain
Raised intracranial pressure,
nerve compression, soft tissue
infiltration, liver pain
Neuropathic pain of any
aetiology
Neuropathic pain of any
aetiology
Neuropathic pain of any
aetiology
Severe neuropathic pain
(only under specialist
supervision)
Side-Effects
Gastric irritation and bleeding,
fluid retention, headache;
caution in renal impairment
Gastric irritation if used
together with NSAID, fluid
retention, confusion,
Cushingoid appearance,
candidiasis, hyperglycaemia
Mild sedation, tremor,
confusion
Vertigo, sedation, constipation,
rash
Sedation, dizziness, confusion,
dry mouth, constipation,
urinary retention; avoid in
cardiac disease
Confusion, anxiety, agitation,
hypertension
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 SIDE EFFECTS OF OPIOIDS
 Constipation
 Nausea and vomiting
 Drowsiness
 Confusion
 Hallucinations and nightmares
 Hyperalgesia- abnormally heightened sensitivity to pain
 Hyperkatafeia - emotional lability induced by long term use
of opioids

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 NON-PHARMACOLOGICAL AND
COMPLEMENTARY TREATMENTS
 Radiotherapy - Bone Metastases
 Physiotherapy
 massage
 application of heat or cold
 exercise
 Psychological techniques
 simple relaxation
 hypnosis
 Acupuncture
 Herbal medicine and homeopathy

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 OPIOIDS
WHERE ARE OPIOID RECEPTORS?
• 1.
• 2.
• 3.

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THE END

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