Pain relief in palliative care

Question 1

What is palliative care?

Answer 1

Palliative care is an approach that improves the quality of life of patients and their families facing 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.

Many patients wish to remain at home with their families.

Question 2

Drug treatment in palliative care

Answer 2

1) The number of drugs should be as few as possible, for even the taking of medicine may be an effort.
2) Oral medication is usually satisfactory unless there is severe nausea and vomiting, dysphagia, weakness, or coma, when parenteral medication may be necessary.

Question 3

What is the focus of pain management in palliative care?

Answer 3

1) Pain management in palliative care is focused on achieving control of pain by administering the right drug in the right dose at the right time.

Question 4

How many classes can analgesics be divided into?

Answer 4

Analgesics can be divided into three broad classes: non-opioid (paracetamol, NSAID), opioid (codeine, morphine) and adjuvant (e.g. antidepressants, antiepileptics).
Drugs from the different classes are used alone or in combination according to the type of pain and response to treatment.
Analgesics are more effective in preventing pain than in the relief of established pain, it is important that they are given regularly.

Question 5

Should the risk of addiction delay the use of opioids in palliative care?

Answer 5

Initiation of an opioid analgesic should not be delayed by concern over a theoretical likelihood of psychological dependence (addiction).

Question 6

What is used for pain management due to bone metastases?

Answer 6

1) In addition to the above approach, radiotherapy, bisphosphonates, and radioactive isotopes of strontium chloride may be useful for pain due to bone metastases.

Question 7

Which drugs are used to treat neuropathic pain?

Answer 7

TCAs
Gabapentin
Antiepileptic drugs
Ketamine

Question 8

Which drugs are used to treat pain due to nerve compression?

Answer 8

Corticosteroids such as dexamethasone- this reduces oedema around the tumour thus reducing nerve compression.

Question 9

How does treatment with morphine work?

Answer 9

1) Treatment with morphine is given by mouth as immediate-release or modified-release preparations.

Question 10

Which factors are considered during the titration of morphine?

Answer 10

During the titration phase, the initial dose is based on: 
•	The previous medication used. 
•	The severity of the pain. 
•	Presence of renal impairment. 
•	Increasing age. 
•	Frailty.

Question 11

How is the dose of morphine given?

Answer 11

The dose is given either as an immediate-release preparation 4-hourly or as a modified-release preparation 12-hourly, in addition to rescues doses.

Question 12

What is breakthrough pain?

Answer 12

Pain that occurs between regular doses of morphine

Question 13

How is breakthrough pain treated?

Answer 13

An additional dose (rescue dose) of immediate-release morphine should be given.

Question 14

What is the standard dose for breakthrough pain?

Answer 14

The standard dose of a strong opioid for breakthrough pain is usually one-tenth to one-sixth of the regular 24-hour dose, repeated every 2-4 hours as required (up to hourly may be needed if pain is severe or in the last days of life).

Question 15

What should be done if there are frequent rescue doses?

Answer 15

Review pain management if rescue analgesic is required frequently (twice daily or more).

Question 16

What should be considered when adjusting the dose of morphine?

Answer 16

When adjusting the dose of morphine, the no. of rescue doses required and the response to them should be taken into account; increments of morphine should not exceed one-third to one-half of the total daily dose every 24 hours.

Question 17

When should upward titration of morphine stop?

Answer 17

When either the pain is relieved or unacceptable adverse effects occur, after which it is necessary to consider alternative measures.

Question 18

What can happen with morphine treatment when the pain is controlled?

Answer 18

Patients started on 4-hourly immediate-release morphine can be transferred to the same total 24-hour dose of morphine given as the modified-release preparation for 12-hourly or 24-hourly administration.

Question 19

Which opioid can be used instead of morphine?

Answer 19

1Oxycodone can be used in patients who require an opioid but cannot tolerate morphine.
If the patient is already receiving an opioid, oxycodone should be started at a dose equivalent to the current analgesic.
Oxycodone immediate-release preparations can be given for breakthrough pain.

Question 20

What is common side effect of morphine?

Answer 20

Constipation. A suitable laxative should be prescribed routinely.
The patient must be monitored closely for efficacy and side-effects, particularly constipation, and nausea and vomiting.

Question 21

Equivalent doses of opioid analgesics

Answer 21

1) Codeine (PO)- 100mg
2) Diamorphine (IM, IV, SC)- 3mg
3) Dihydrocodeine (PO) – 100mg
4) Hydromorphone (PO)- 2 mg
5) Morphine (PO)- 10 mg
6) Morphine (IM, IV, SC)- 5 mg
7) Oxycodone (PO)- 6.6 mg
8) Tramadol (PO)- 100 mg

Question 22

What are syringe drivers?

Answer 22

1) Although drugs can usually be administered by mouth to control the symptoms of advanced cancer, the parenteral route may sometimes be necessary.
2) Portable continuous infusion devices, such as syringe drivers can provide good control of symptoms with little discomfort or inconvenience to the patient.

Question 23

What are the indications for the parenteral route in palliative care?

Answer 23

• The patient is unable to take medicines by mouth owing to nausea and vomiting, dysphagia, severe weakness, or coma.
• There is malignant bowel obstruction in patients for whom further surgery is inappropriate.
• Occasionally when the patient does not wish to take regular medication by mouth.

Question 24

Why is it important that only trained staff use the syringe driver?

Answer 24

Incorrect use is a common cause of medication error.

Question 25

What are common problems experienced with a syringe driver?

Answer 25

• If the subcutaneous infusion runs too quickly check the rates set and the calculation;
• lf the subcutaneous infusion runs too slowly check the start button, the battery, the syringe driver, the cannula, and make sure that the injection site is not inflamed .
• if there is an injection site reaction make sure that the sides does not need to be changed-firmness or swelling at the site of injection is not in itself an indication for change, but pain or obvious information is.