The Mary Stevens Hospice The Mary Stevens Hospice StourbridgeStourbridge

Lucy Martin - Medical DirectorLucy Martin - Medical Director

(BCVTS 1997 – 2000!)(BCVTS 1997 – 2000!)

VTS March 4VTS March 4thth 2010 2010

1.301.30 Session on Palliative Care and Session on Palliative Care and Basics of Pain Control, plus Basics of Pain Control, plus discussion and questionsdiscussion and questions

2.45 2.45 Coffee / TeaCoffee / Tea

3.003.00 Case discussion 1 & feedbackCase discussion 1 & feedback

3.453.45 Case discussion 2 & feedbackCase discussion 2 & feedback

4.304.30 Plenary and closePlenary and close

What is Palliative Care?What is Palliative Care?

WHO DefinitionWHO Definition

Palliative care is an approach that Palliative care is an approach that improves the quality of life of patients and improves the quality of life of patients and their families facing the problem their families facing the problem associated with life-threatening illness, associated with life-threatening illness, through the prevention and relief of through the prevention and relief of suffering by means of early identification suffering by means of early identification and impeccable assessment and and impeccable assessment and treatment of pain and other problems, treatment of pain and other problems, physical, psychosocial and spiritual. physical, psychosocial and spiritual.

provides relief from pain and other distressing provides relief from pain and other distressing symptomssymptoms

affirms life and regards dying as a normal affirms life and regards dying as a normal processprocess

intends neither to hasten or postpone deathintends neither to hasten or postpone death

integrates the psychological and spiritual integrates the psychological and spiritual aspects of patient careaspects of patient care

offers a support system to help patients live as offers a support system to help patients live as actively as possible until deathactively as possible until death

offers a support system to help the family cope offers a support system to help the family cope during the patient's illness and in their own during the patient's illness and in their own bereavementbereavement

uses a team approach to address the needs of uses a team approach to address the needs of patients and their families, including patients and their families, including bereavement counselling, if indicatedbereavement counselling, if indicated

will enhance quality of life, and may also will enhance quality of life, and may also positively influence the course of an illnesspositively influence the course of an illness

is applicable early in the course of illness, in is applicable early in the course of illness, in conjunction with other therapies that are conjunction with other therapies that are intended to prolong life, such as chemotherapy intended to prolong life, such as chemotherapy or radiation therapy, and includes those or radiation therapy, and includes those investigations needed to better understand and investigations needed to better understand and manage distressing clinical complications.manage distressing clinical complications.

Who provides Palliative Care?Who provides Palliative Care?

GeneralistGeneralistGPs, District Nurses, HospitalsGPs, District Nurses, Hospitals

Providing day-to-day care in hospital or patients homeProviding day-to-day care in hospital or patients home

SpecialistSpecialistPalliative Care Teams based in hospices, hospitals, Palliative Care Teams based in hospices, hospitals, communitycommunity

Multidisciplinary – Core members are doctors & nurses, Multidisciplinary – Core members are doctors & nurses, AHPsAHPs

In-patient and Day care facilities, hospice at homeIn-patient and Day care facilities, hospice at home

Ongoing advice and support in any settingOngoing advice and support in any setting

Bereavement supportBereavement support

Education and training for specialists and generalistsEducation and training for specialists and generalists

Day care since 1993, and residential since 1999Day care since 1993, and residential since 1999Referral form @ Referral form @ www.marystevenshospice.co.uk

Specialist Palliative Care in Specialist Palliative Care in DudleyDudley

Hospice in-patient care / day careHospice in-patient care / day careMary Stevens covers the whole Dudley boroughMary Stevens covers the whole Dudley borough

Hospital in-patient care Hospital in-patient care no dedicated hospital bedsno dedicated hospital beds

0.4 WTE consultant – out pt and consultation0.4 WTE consultant – out pt and consultation

hospital palliative care team & MDT meetinghospital palliative care team & MDT meeting

Community ServiceCommunity ServiceMacmillan CNS and OT / Physio teamMacmillan CNS and OT / Physio team

Palliative Care end of life teamPalliative Care end of life team

What you know about pain management?What you know about pain management?

What do you feel confident about?What do you feel confident about?

What makes you nervous?What makes you nervous?

WHO ladder / liftWHO ladder / lift

Cancer and non-cancer chronic painCancer and non-cancer chronic pain

Dudley Pain Management GuidelinesDudley Pain Management Guidelines

Principles of analgesic usePrinciples of analgesic useBy the mouthBy the mouth

By the clockBy the clock

By the ladderBy the ladder– Refers to WHO analgesic ladderRefers to WHO analgesic ladder

Treatment should be individualisedTreatment should be individualised

Use adjuvantsUse adjuvants– Drugs for specific situations e.g. NeuropathyDrugs for specific situations e.g. Neuropathy– Drugs to control side effectsDrugs to control side effects– PsychotropicsPsychotropics

Twycross, R ‘Introducing Palliative Care’, ‘Symptom management of advanced cancer’Twycross, R ‘Introducing Palliative Care’, ‘Symptom management of advanced cancer’

Strong opioidsStrong opioids

Should be given according to need and Should be given according to need and responseresponse

Should not be given according to Should not be given according to prognosisprognosis

Administration still surrounded by concernAdministration still surrounded by concern

Little clinically significant respiratory Little clinically significant respiratory depression, tolerance not a problem, depression, tolerance not a problem, dependence does not occurdependence does not occur

Naloxone – very rareNaloxone – very rare

Patients generally have been receiving Patients generally have been receiving weak opiates firstweak opiates first

Dose gets titrated – ‘start low, go slow’Dose gets titrated – ‘start low, go slow’

Pain is an antagonist to central depressant Pain is an antagonist to central depressant effects of strong opiateseffects of strong opiates

Therapeutic dose vs. toxic / lethal doseTherapeutic dose vs. toxic / lethal dose

Opioids in the well person Opioids in the well person (or How I did it by H. Shipman) (or How I did it by H. Shipman)

Opioids in Cancer Pain Opioids in Cancer Pain (and probably non-cancer pain too)(and probably non-cancer pain too)

MorphineMorphine

ProsPros

200+ years of experience200+ years of experience

CheapCheap

4 formulations – IR elixir 4 formulations – IR elixir and tablet, SR liquid and and tablet, SR liquid and tablet / capsuletablet / capsule

Flexibility in dosing, Flexibility in dosing, multiple strengths multiple strengths available, flexible routesavailable, flexible routes

Predictable titration Predictable titration scheduleschedule

ConsCons

Metabolites accumulate Metabolites accumulate in brain and CSF if renal in brain and CSF if renal dysfunctiondysfunction

20 – 30 % population do 20 – 30 % population do not toleratenot tolerate

Equivalent DosesEquivalent DosesComfortable Dose for Rx Comfortable Dose for Rx

Codeine 60mg qds p.o.Codeine 60mg qds p.o.

Dihydrocodeine 60mg Dihydrocodeine 60mg qds p.o.qds p.o.

Pethidine 50mg qds p.o.Pethidine 50mg qds p.o.

Tramadol 100mg qds p.o.Tramadol 100mg qds p.o.

Fentanyl 25mcg t.d.Fentanyl 25mcg t.d.

Diamorphine 2.5mg s.c. Diamorphine 2.5mg s.c. every 30 minsevery 30 mins

Equivalent 24hr Morphine DoseEquivalent 24hr Morphine Dose

Morphine 25mgMorphine 25mg

Morphine 25mgMorphine 25mg

Morphine 25mgMorphine 25mg

Morphine 40 - 80mgMorphine 40 - 80mg

Morphine 60mgMorphine 60mg

Morphine 7.5mg p.o. Morphine 7.5mg p.o. every 30 minsevery 30 mins

Titrating in the communityTitrating in the community

Easiest method is the 4-hourly plus rescueEasiest method is the 4-hourly plus rescue1.1. Calculate current morphine equivalent / 24hrCalculate current morphine equivalent / 24hr

2.2. +/- make allowance for uncontrolled pain+/- make allowance for uncontrolled pain

3.3. Divide by 6Divide by 6

4.4. 4 hourly dose / rescue dose4 hourly dose / rescue dose

5.5. 2 – 3 days record2 – 3 days record

6.6. Review, then divide and convert to sustained Review, then divide and convert to sustained release prep, plus rescue (1/6release prep, plus rescue (1/6 thth of total daily of total daily dose)dose)

Increasing doses of opioidIncreasing doses of opioid

Gradual escalation of doses if pain control Gradual escalation of doses if pain control inadequateinadequate

Dose escalations of less than 30 – 50% are Dose escalations of less than 30 – 50% are unlikely to have much effectunlikely to have much effect

Experience shows 30 – 50% dose increases Experience shows 30 – 50% dose increases are safeare safe

Absolute dose is immaterial as long as Absolute dose is immaterial as long as balance between analgesia / side effectsbalance between analgesia / side effects

Less is known about titration for dyspneaLess is known about titration for dyspnea

Why / when to switch opioidWhy / when to switch opioidIntolerable side effectsIntolerable side effects

Itching, neurotoxicity, that persist despite appropriate Itching, neurotoxicity, that persist despite appropriate interventionintervention

Lack of desired analgesic effectLack of desired analgesic effectEven with rapidly escalating dosesEven with rapidly escalating doses

Moderate or severe renal diseaseModerate or severe renal diseaseEgfr <60 ??Egfr <60 ??

Alternative route is requiredAlternative route is required

Unstable pain on a patchUnstable pain on a patch

Patient’s personal choice / opiophobiaPatient’s personal choice / opiophobia

DiamorphineDiamorphine

ProsPros

CheapCheap

May work via receptors May work via receptors other than µ - explaining other than µ - explaining the apparent differences the apparent differences with morphinewith morphine

More soluble / lipophilic More soluble / lipophilic than morphine – parenteral than morphine – parenteral use /small volumesuse /small volumes

Quicker action, less Quicker action, less vomitingvomiting

Cons Cons

Not useful orallyNot useful orally

More sedating than More sedating than morphinemorphine

Fear / preconceptions of Fear / preconceptions of patients and HCPspatients and HCPs

OxycodoneOxycodone

ProsPros

Potent drug orallyPotent drug orally

Flexibility in SR dose Flexibility in SR dose formulationsformulations

Effective levels within 1 Effective levels within 1 hour – good for titrationhour – good for titration

Rectal formulationRectal formulation

Metabolites not part of the Metabolites not part of the analgesic pictureanalgesic picture

Possibility of neuropathic Possibility of neuropathic effecteffect

ConsCons

Differing views in different Differing views in different countries – USA see it as countries – USA see it as a step 2 druga step 2 drug

Common drug of abuse in Common drug of abuse in USAUSA

Hydromorphone (palladone)Hydromorphone (palladone)

ProsPros

Multiple routes of admin – Multiple routes of admin – oral, parenteral, rectal oral, parenteral, rectal and intraspinaland intraspinal

Very soluble – good for Very soluble – good for subcut usesubcut use

ConsCons

Oral dosing complicated Oral dosing complicated and oral breakthrough and oral breakthrough dose multiple capsulesdose multiple capsules

Difficulty predicting dose Difficulty predicting dose equivalency with equivalency with morphinemorphine

Fentanyl & alfentanilFentanyl & alfentanil

ProsPros

Transdermal delivery due Transdermal delivery due to lipophilic natureto lipophilic nature

Intravenous – rapid onset Intravenous – rapid onset of actionof action

Buccal / sublingual / Buccal / sublingual / intranasal immediate intranasal immediate release formulationrelease formulation

Convenience / Convenience / compliancecompliance

Possibly less constipationPossibly less constipation

ConsCons

Delay of effective Delay of effective analgesia 8 -12 hrs initiallyanalgesia 8 -12 hrs initially

Poor dosing flexibilityPoor dosing flexibility

Uncertainty with BMIUncertainty with BMI

CostCost

Contraindication in Contraindication in uncontrolled pain due to uncontrolled pain due to titration periodtitration period

Patch adhesion problemsPatch adhesion problems

MethadoneMethadone

ProsPros

Potent orallyPotent orally

Useful in pain with Useful in pain with neurological componentsneurological components

ConsCons

Unpredictable Unpredictable accumulation / plasma accumulation / plasma concentration rises over concentration rises over long periods – long periods – unpredictable side effectsunpredictable side effects

Steady state ~ 1 weekSteady state ~ 1 week

Not really practical in Not really practical in community settingcommunity setting

Please don’t forgetPlease don’t forget

ConstipationConstipation– senna/ lactulosesenna/ lactulose– movicolmovicol– co-danthrusate / co-danthramerco-danthrusate / co-danthramer

NauseaNausea– metoclopramide / domperidonemetoclopramide / domperidone– haloperidolhaloperidol

Where to look for information?Where to look for information?

Twycross books are the ‘bibles’Twycross books are the ‘bibles’Palliative Care Formulary – 3Palliative Care Formulary – 3rdrd Edition Edition

Symptom management of advanced cancer - 4Symptom management of advanced cancer - 4thth Edition Edition

Introducing Palliative CareIntroducing Palliative Care

Palliativedrugs.com – online version of PCFPalliativedrugs.com – online version of PCF

More detailMore detailOxford Textbook of Palliative MedicineOxford Textbook of Palliative Medicine

West Midlands pain handbookWest Midlands pain handbook