Managing Pain. Preconference SHPCA Clinical Day Saskatoon, SK May 13, 2014

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Poppy Perkins
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1 Preconference SHPCA Clinical Day 2014 Saskatoon, SK May 13, 2014 Carmen L. Johnson MD, CCFP, ABFP, AAHPM, AAPM, ABAM, ABRPM (Pain Medicine) Medical Director Palliative Care Services, Regina Qu Appelle Health Region

2 Outline Definitions - Pain - Total pain Treatment of Pain Managing Pain Treatment of Pain in Patients with Addictive Disease Case Studies in Pain

3 Pain sensation (conscious awareness of a noxious [nasty] stimulus, physical or mental) emotional response experience (intense feelings of displeasure resulting in a set of behaviors).

4 Pain is a Mind and Body Experience Stimulus Pain Suffering Pain Behavior

5 Biopsychosocial Assessment biological pain (pain in the body) psychosocial pain tend to focus on biological pain cancer, chronic pain psychological factors more prominent

6 Pain common, devastating complication of progressive, incurable illnesses advanced cancer, AIDS end-stage heart and lung diseases brain and nerve (neurological) diseases

7 Pain 85% of cancer patients experience pain 90% of cancer pain can be managed

8 Total Pain Dame Cecilia. Saunders Social worker, nurse, physician Early founder, UK hospice movement

9 Total Pain

10 Pain & Suffering not synonyms physical pain may cause suffering suffer without physical pain

11 Suffering many sources all can increase physical pain can be dependent on meaning of pain i.e. pain of post op healing vs. childbirth vs. cancer recurrence

12 Suffering meaning of pain within patient s family, culture, and religious faith determines (to a large extent) the suffering experience

13 Suffering Other Factors: psychological problems severe existential distress inability to trust others major depression

14 Suffering Other Factors: unresolved guilt deep wounds, childhood abuse, neglect, death or abandonment

15 Communication communication skills essential to assess and treat cancer pain communication does not necessarily mean talking, but listening

16 Communication listening for patient s questions communication means to connect doctor-patient relationship - mutual trust foundation of pain management

17 Communication Team-Patient Relationship mutual trust foundation of excellence in palliative care

18 Patient s Questions Disease What is cancer? Could I have prevented it? Was it my fault? Is it hereditary? Infectious?

19 Patient s Questions Treatment What s going to happen now? What treatment will I get? What are the side effects?

20 Patient s Questions What Changes Will Occur in My Body? Physical appearance? Sex life? Will I be able to eat?

21 Patient s Questions What Changes Will Occur in My Body? Will the tumor recur? How will it spread? How will I feel?

22 Patient s Questions Social Will I go back to work? Family relationships? How will my friends react?

23 Patient s Questions Pain What will the pain-relievers do to me? Will the pain get worse? Addiction? Personality change?

24 Patient s Questions Pain Will I lose control and go crazy with pain? Will I get dopey? Will I become helpless?

25 Patient s Questions Prognosis How serious is this? Is there no more treatment? Am I going to die?

26 Patient s Questions Prognosis How long do I have? What will happen at the end? Will there be pain? Choking? Bleeding?

27 Communication Managing Pain many questions never clearly formed mind of the patient or family active listening encourages information exchange

28 Communication Managing Pain many questions have no answers or only partial answers patients/families need questions heard by caregivers even if questions are not spoken

29 Communication Managing Pain Comforting Phrases: I care about how you are suffering I believe we can relieve your pain No matter what happens, we will care for you

30 Comfort enhanced through regular visits repeated thorough examinations detailed explanations consistent coordinated team

31 Meaning important to attack the physiology and psychology of pain must join patient/family in a search for meaning and hope

32 Meaning degree of suffering depends on context of meaning in which pain is experienced unrelieved pain leads to helplessness and hopelessness greatest source of suffering for patient, family and caregiver

33 Meaning Pain Forces All of Us to deepen or seek new religious or philosophical perspectives on death and life

34 Fear at the center of pain overwhelming and unspoken sense of terror without specific focus permission to discuss openly help patient give fear a name

35 Questions What are you afraid of? death? losing control? cancer treatment? hair loss? disfigurement? bleeding?

36 Questions What are you afraid of? being left alone? process of dying? addiction? pain? vomiting? going crazy? suffocating? family bankruptcy?

37 Fear fear of cancer pain intertwined with all other fears therapy must address each fear with accurate information counteract unrealistic beliefs, expectations

38 Fear patient participation in treatment plan measurable, achievable goals i.e. realistic hope positive attitudes in palliative care team consistency, availability in follow-up

39 Approach to Psychological and Spiritual Components of Suffering L E T G O Listen to the patient s story. Encourage the search for meaning. Tell of your concern and acknowledge the pain of loss. Generate hope wherever possible. Own your limitations, gain competence in palliative care, refer when appropriate.

41 Treatment of Pain Managing Pain prevent pain don t chase it proactive, not reactive, don t delay pain rating frequently use pain scale

42 Treatment of Pain Managing Pain respond immediately if pain increases by the clock 24 hour pain relief breakthrough pain doses incident pain

43 Treatment of Pain Routes for Analgesia by the mouth preferred, effective under skin, through cheek, via rectum NO intramuscular injections

44 Treatment of Pain Transdermal (through the skin) fentanyl - must have stable pain control decreased efficacy cachectic, obese patients Topical (on the skin) compounded gels/powders - open painful ulcers

45 Treatment of Pain Managing Pain Axial Analgesia (needle along the spine) intraspinal epidural intrathecal

46 Treatment of Pain Managing Pain know source(s) of pain individualize pain mngt different pain generators require different treatment neuropathic pain, spinal cord compression

47 Treatment of Pain Managing Pain treat pain not directly associated with terminal illness gastritis, constipation, oral/esophageal thrush side effects - chemotherapy

48 Treatment of Pain Managing Pain Identify and Treat Underlying Causes: cancer, chemo or hormonal treatment? infections, aggravate pain * antibiotics other diseases

49 Treatment of Pain Managing Pain WHO ladder as an analgesic guideline

50 Treatment of Pain Managing Pain Consider Other Therapies: palliative radiation therapy palliative chemotherapy hormone therapy

51 Treatment of Pain Consider Other Therapies: pinning unstable bones taking out pieces of spine bones relieve pressure on spinal cord gluing spine bones together vertebroplasty/kyphoplasty

52 Treatment of Pain Consider Other Therapies: cutting spinal cord myelotomy, cordotomy destroying nerves celiac plexus block, intrathecal neurolytic radiofrequency ablation - ultrasound

53 Treatment of Pain Consider Other Therapies: numb an area of the body motor/sensory block intercostal; trigeminal spinal cord level epidural/intrathecal

54 Treatment of Pain Consider Other Therapies: nerve stimulation implants in brain implants along spinal cord

55 Treatment of Pain Individualize the Regimen different responses to different opioids and doses to adjunct medications

56 Treatment of Pain increase dose until comfort obtained continue to take medication as prescribed some patients believe they don t need the medication when pain relieved

57 Treatment of Pain Expect Opioid Dose to Increase Over Time disease progression tolerance especially in young (neuroplasticity) hx of addictive disease

58 Treatment of Pain Managing Pain If Tolerance a Problem or Poor Pain Control switch to another opioid

59 Treatment of Pain Prevent Constipation use laxatives +/- stool softeners enemas, suppositories prn No bulking agents (Metamucil)

60 Treatment of Pain Use Medications that Treat Pain in a Different Way - Adjuncts anti-depressants anti-convulsants steroids

61 Treatment of Pain Managing Pain maintain the human touch medication works best when patient s psychological and social needs are met companionship, respite for family, good-natured team members, professional delivery of services, diversions

62 Treatment of Pain address all aspects of suffering remember total pain, total suffering spiritual and psychosocial support manage other symptoms

63 Treatment of Pain in Patients with Addictive Disease Addiction 8 12 % of population

64 Pain & Addiction Addiction: Managing Pain a pattern of dysfunctional (stupid) behavior associated with specific behaviors or substances

65 Pain & Addiction Addiction: behavior continues despite significant harm loss of control

66 Pain & Addiction Tolerance normal physiological response increased dosing needed for pain control

67 Pain & Addiction Tolerance tolerance very common in younger patients ( neuroplasticity of brain) significant tolerance uncommon in elderly if a problem use other medications

68 Pain & Addiction Physical dependence normal physiological response opioid withdrawn or decreased withdrawal symptoms does not imply addiction

69 Pain & Addiction Managing Pain Pain is what the patient says it is except when it is not!

70 Pain & Addiction patient may have active addiction issues patient may have a history of addictive disease patient with no history of addiction may develop a problem genetic susceptibility

71 Pain & Addiction careful evaluation of symptoms anatomical pattern - location 2 major pain types nociceptive, neuropathic

72 Pain & Addiction Nociceptive Pain Receptors in Body a) Somatic Managing Pain - superficial - skin, well localized, sharp - deep - Musculoskeletal muscle, bone, joints, ligaments aching, more diffuse, can be sharp and radiate

73 Pain & Addiction Nociceptive Pain Receptors in Body b) Visceral - viscera, peritoneum pleural cavity - poorly localized

74 Pain & Addiction Managing Pain Neuropathic Dysfunction of Nervous System brain and nerves function abnormally in pain transmission and perception difficult to treat usually need several different medications

75 Pain & Addiction Patients With Addictive Disease Usually Need Higher Doses of Analgesics: changes in brain functioning develop tolerance quicker

76 Pain & Addiction Methadone dose for harm reduction doesn t give analgesia increase the methadone dose dose several times daily use adjuncts

77 Pain & Addiction Methadone Managing Pain preferred analgesic methadone not as much street value special properties reduce risk or rate of tolerance

78 Pain & Addiction Other Interventions Managing Pain limit amount of opiates available at a time if stolen/diverted fewer pills available on street

79 Pain & Addiction Other Interventions Managing Pain patient often will have better control of medication use with # of pills if on daily methadone for harm reduction consider 2 nd dose carry to improve analgesia

80 Pain & Addiction Goals Managing Pain reduce risk of abuse/diversion provide appropriate pain and symptom management

81 Margaret: A Case Study in Pain

82 Harvey: A Case Study in Pain

83 Ms. Clarke: A Case Study in Pain

84 References Managing Pain, Canadian Pain Society, 2008 Primer of Palliative Care, AAHPM, 2007 Wikipedia, Dame Cecilia Saunders, 2014 American Society of Addiction Medicine American Academy of Hospice & Palliative Medicine

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