60 Second Summary: The WHO defines palliative care as “the active total care of patients whose disease is not responsive to curative treatment. The goal of which is to achieve the best quality of life for patients and their families.” As such, effective palliative pain management is paramount6.Palliative care requires a multidisciplinary approach to working. It is unrealistic to expect one profession or individual to have the skills to make the necessary assessment, institute the required interventions, and provide ongoing monitoring for patients2. Community pharmacists are one such profession that have a key role to play in securing the delivery of high quality palliative care and in particular pain management.
Sponsored by Pfizer Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ie CPD 24: PALLIATIVE PAIN MANAGEMENT Palliative Pain Management 60 Second Summary The WHO defines palliative care as “the active total care of patients whose disease is not responsive to curative treatment. The goal of which is to achieve the best quality of life for patients and their families.” As such, effective palliative pain management is paramount 6 . Palliative care requires a multidisciplinary approach to working. It is unrealistic to expect one profession or individual to have the skills to make the necessary assessment, institute the required interventions, and provide ongoing monitoring for patients 2 . Community pharmacists are one such profession that have a key role to play in securing the delivery of high quality palliative care and in particular pain management. Pain management requires assessment of the physical, functional, psychosocial and spiritual aspects of pain 3,4 . Once analgesic requirements are determined, treatment should be initiated in accordance with the recommendations of the WHO analgesic ladder 6 . Pharmacists are ideally placed to ascertain the success of pain management plans, troubleshoot side-effects, provide reassurance and guidance and encourage patients to take an active role in their care. ASSESSMENT OF PAIN Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is a complex subjective phenomenon and one that is affected by the emotional context in which it is endured 3 . Prior to initiating treatment, an accurate assessment should be performed to determine the cause, type and severity of pain and its effect on the patient. Ideally, the patient should be the prime assessor of pain. A pain assessment should include: • physical effects/manifestations of pain • functional effects (interference with activities of daily living • psychosocial factors – level of anxiety, mood, fears, effects on interpersonal relationships, factors affecting pain tolerance 3 . Psychosocial factors are undoubtedly an important consideration given adequate psychological support can remove fear, helping to optimise pain control 4 . PRINCIPLES OF PAIN MANAGEMENT Patients with palliative pain should have their treatment outcomes monitored regularly using visual analogue, numerical rating or verbal rating scales. Self-assessment pain scales should be used in patients with cognitive impairment, where feasible 3 . It is important that patients are given adequate information and instruction about their pain management and encouraged to take an active role. The principles of treatment outlined in the World Health Organisation (WHO) pain relief strategy should be adhered to when deciding on appropriate analgesia 5 . WHO ANALGESIC LADDER The use of analgesics should be cross- 1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice. 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area. 3. PLAN - If I have identified a knowledge gap - will this article satisfy those needs - or will more reading be required? 4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs? 5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings. Published by IPN and supported with an unrestricted educational grant from Pfizer Healthcare Ireland. Copies can be downloaded from www.irishpharmacytraining.ie Disclaimer: All material published in CPD and the Pharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author. INTRODUCTION: Appropriate pain management is a common complication of many advanced and progressive diseases 1 . It is estimated that three-quarters of advanced cancer and two-thirds of progressive non-malignant disease patients experience pain that requires treatment with strong opioid analgesics 2 . Yet, despite the relative availability of such therapies, published evidence suggests that palliative pain remains under-treated. As such, effective management of palliative pain is an important global public health issue 1 . Biography - Aaron Carlyle (MPharm MPSNI MPSI) is the supervising manager pharmacist at Brennan's Pharmacy in Buncrana, Co Donegal. He is a graduate of the University of Manchester, with a Master of Pharmacy degree. He completed his pharmacy training with Boots as a pre-registration pharmacist. Carlyle joined Brennan's in a group support pharmacist role in 2010, and took over management of the Buncrana branch later that year. In addition to his work as a community pharmacist, Carlyle is also involved in pharmacy education. He is a qualified pharmacy assessor and writes pharmacy training courses for clients in both the UK and Ireland.
Transcript
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CPD 24: PALLIATIVE PAIN MANAGEMENT
Palliative Pain Management60
Second SummaryThe WHO defines palliative care as “the active total care of patients whose disease is not responsive to curative treatment. The goal of which is to achieve the best quality of life for patients and their families.” As such, effective palliative pain management is paramount6.
Palliative care requires a multidisciplinary approach to working. It is unrealistic to expect one profession or individual to have the skills to make the necessary assessment, institute the required interventions, and provide ongoing monitoring for patients2. Community pharmacists are one such profession that have a key role to play in securing the delivery of high quality palliative care and in particular pain management.
Pain management requires assessment of the physical, functional, psychosocial and spiritual aspects of pain3,4. Once analgesic requirements are determined, treatment should be initiated in accordance with the recommendations of the WHO analgesic ladder6. Pharmacists are ideally placed to ascertain the success of pain management plans, troubleshoot side-effects, provide reassurance and guidance and encourage patients to take an active role in their care.
ASSESSMENT OF PAINPain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is a complex subjective phenomenon and one that is affected by the emotional context in which it is endured3.
Prior to initiating treatment, an accurate assessment should be performed to determine the cause, type and severity of pain and its effect on the patient. Ideally, the patient should be the prime assessor of pain. A pain assessment should include:
• physical effects/manifestations of pain
• functional effects (interference with activities of daily living
• psychosocial factors – level of anxiety, mood, fears, effects on interpersonal relationships, factors affecting pain tolerance3.
Psychosocial factors are undoubtedly an important consideration given adequate psychological support can remove fear, helping to optimise pain control4.
PRINCIPLES OF PAIN MANAGEMENTPatients with palliative pain should have their treatment outcomes monitored regularly using visual analogue, numerical rating or verbal rating scales. Self-assessment pain scales should be used in patients with cognitive impairment, where feasible3.
It is important that patients are given adequate information and instruction about their pain management and encouraged to take an active role. The principles of treatment outlined in the World Health Organisation (WHO) pain relief strategy should be adhered to when deciding on appropriate analgesia5.
WHO ANALGESIC LADDERThe use of analgesics should be cross-
1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice.
2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area.
3. PLAN - If I have identified a knowledge gap - will this article satisfy those needs - or will more reading be required?
4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs?
5. WHAT NEXT - At this time you may like to record your learning for future use or
assessment. Follow the 4 previous steps, log and record your findings.
Published by IPN and supported with an unrestricted educational grant from Pfizer Healthcare Ireland. Copies can be downloaded from www.irishpharmacytraining.ie
Disclaimer: All material published in CPD and the Pharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author.
INTRODUCTION: Appropriate pain management is a common complication of many advanced and progressive diseases1. It is estimated that three-quarters of advanced cancer and two-thirds of progressive non-malignant disease
patients experience pain that requires treatment with strong opioid analgesics2. Yet, despite the relative availability of
such therapies, published evidence suggests that palliative pain remains under-treated. As such, effective management of palliative pain is an important global public health issue1.
Biography - Aaron Carlyle (MPharm MPSNI MPSI) is the supervising manager pharmacist at Brennan's Pharmacy in Buncrana, Co Donegal. He is a graduate of the University of Manchester, with a Master of Pharmacy degree. He completed his pharmacy training with Boots as a pre-registration pharmacist. Carlyle joined Brennan's in a group support pharmacist role in 2010, and took over management of the Buncrana branch later that year. In addition to his work as a community pharmacist, Carlyle is also involved in pharmacy education. He is a qualified pharmacy assessor and writes pharmacy training courses for clients in both the UK and Ireland.
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CPD 24: PALLIATIVE PAIN MANAGEMENT
referenced with the WHO analgesic ladder. A patient’s treatment should start at the step of the ladder most appropriate for the severity of pain and ascend in accordance with response to medication in terms of both efficacy and side-effects.
Step 1 = non-opioid ± adjuvant
Step 2 = weak opioid ± non-opioid ± adjuvant
Step 3 = strong opioid ± non-opioid ± adjuvant
(Adjuvants include corticosteroids, antidepressants and anticonvulsants)6.
OPIOID CLASSIFICATION Opioids are classified as either strong or weak. Strong opioids differ from weak opioids in that they have a much broader dose range and a proportionately greater effect can be achieved by increasing the dose in opioid-sensitive pain. As such, they are useful in the management of pain associated with advanced and progressive disease7.
The term “opioid” refers to all compounds that bind to opioid receptors, which are widely distributed throughout the body. When binding occurs, analgesia may be
accompanied by any of a diverse array of side-effects related to the activation of receptors involved in other functions. These may have an effect on peristalsis (leading to constipation), or an effect on the CNS (leading to drowsiness or respiratory depression)5.
MORPHINE Morphine is the standard against which other analgesics are compared. The pharmacokinetics of which mean that older people may require smaller doses due to receptor sensitivity and impaired renal function, while anxious individuals may require a larger than expected dose. Sedation, dizziness, nausea and constipation are often problematic, as with all opioid analgesics, and are especially common in the frail or elderly and when using large doses. However, despite these side-effects, morphine is remarkably effective and safe to use8.
DIAMORPHINEDiamorphine is a prodrug of morphine. It is very lipid soluble, rapidly crossing tissue membranes, exerting a more rapid onset of action than morphine. So too, its duration of action is comparably shorter. It is this rapid
onset and offset that greatly increases its addiction potential relative to morphine9.
OXYCODONE Oxycodone has similar side- effects to morphine, but possibly less sedation. It is used second-line in patients in whom morphine is inappropriate or not tolerated. The use of oxycodone has increased over the last few years and so too has its cost to the health service, given its considerably greater expense relative to morphine5.
FENTANYLIts highly lipophilic nature (500 times that of morphine) allows fentanyl to be administered via the sublingual, buccal, nasal, and transdermal routes. Thus offering greater flexibility with respect to routes of administration10.
BUPRENORPHINEBuprenorphine undergoes high first-pass liver metabolism if swallowed making it unsuitable for oral administration. Its high lipid solubility (200 times that of morphine) means it is readily absorbed from the oral mucosa or transdermally. Hence, it is very effective when administered sublingually or as a transdermal preparation5.
Figure 1. New adaptation of the analgesic ladder
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CPD 24: PALLIATIVE PAIN MANAGEMENT
TRAMADOL
Although tramadol has some opioid activity, the majority of its efficacy is through noradrenaline and serotonin reuptake inhibition. Since it lowers seizure threshold, it is best avoided in patients with a history of epilepsy. It should also be used with caution in patients concurrently prescribed TCAs, given their similar mechanism of action11.
INITIATING TREATMENT
Prior to initiating treatment with opioid analgesics, it is important to ascertain if a patient has any concerns in relation to:
• addiction
• tolerance
• side-effects
• treatment signifying death
Patients and/or their carers should be provided with verbal and written information to include the following:
• when and why opioid analgesics are used to treat pain
• relative likelihood of effectiveness
• when and how frequently doses should be taken
• possible side-effects and signs of toxicity
• safe storage
• necessary follow-up2
Patients should be commenced on regular oral sustained or immediate-release morphine (depending on patient preference), with rescue doses of oral immediate-release morphine for breakthrough pain. In the
absence of renal or hepatic impairment, patients should be prescribed a typical total daily starting dose of 20-30mg of oral morphine (e.g. 10-15mg oral sustained-release morphine twice daily), plus 5mg oral immediate-release morphine for breakthrough pain. The dose should be titrated until a good balance exists between acceptable pain control and side-effects. As such, it is imperative that patients are reviewed on a regular basis during the initiation phase2.
FIRST-LINE MAINTENANCE THERAPY
Patients should be offered oral sustained-release morphine as first-line maintenance therapy. For patients in whom oral opioids are unsuitable for use, the transdermal and subcutaneous routes may be considered. Caution is required when calculating opioid equivalence.
• A fentanyl 12 microgram/hr patch equates to approximately 45mg oral morphine daily
• 10mg oxycodone injection equates to approximately 40mg oral morphine daily2
FIRST-LINE BREAKTHROUGH TREATMENT
Patients receiving maintenance treatment with oral morphine should be offered oral immediate-release morphine for first-line treatment of breakthrough pain2.
MANAGEMENT OF SIDE-EFFECTS
It is estimated that 80% of patients taking opioids will experience at least one side-effect, of which the most common are constipation, nausea and vomiting, drowsiness, pruritis and respiratory
depression. Opioid side-effects can impair quality of life, increase morbidity and may cause a patient to use less than the prescribed dose or discontinue therapy completely. Tolerance to certain side-effects may occur within the first few days of initiating treatment, e.g. nausea and sedation often become less problematic after 1-2 weeks of treatment, while constipation and pruritis have a tendency to persist12. As such, prescribing physicians, nurses and pharmacists should anticipate, identify and treat common opioid-associated side-effects.
CONSTIPATION
Constipation is one of the most common opioid-related side-effects, that does not tend to resolve with continued treatment. Research suggests that constipation is in fact one of the most problematic side-effects given its relative impact on quality of life and the frequency at which it occurs12. As such, an effective regimen of laxatives should be initiated upon commencing opioid therapy. A stool softener and stimulant are generally the preferred options, although bulk-forming and osmotic laxatives can also be used5.
NAUSEA AND VOMITING
It is estimated that opioid-induced nausea and vomiting effects up to one quarter of patients, although untreated pain itself can induce nausea. Gradual dose titration can reduce the likelihood of occurrence. When nausea and vomiting do occur, symptomatic relief may be gained with the use of cyclizine or prochlorperazine, with symptoms having a tendency to diminish over days or weeks of continued opioid exposure8.
DROWSINESS
Sedation most frequently occurs upon initiation of opioid therapy. Symptoms do however frequently resolve after a few days of exposure, in which case reassurance often proves sufficient. In cases where sedation persists, concurrent medication therapies should be reviewed5.
PRURITIS
Pruritis occurs in approximately 1% of patients. Opioids cause a histamine release from mast cells, albeit to varying degrees, which may account for the sensation of itch. Routine treatment is with the use of antihistamines12.
RESPIRATORY DEPRESSION
Onset is most likely when there have been major changes in dose, formulation or route of administration. Accidental overdose is likely to be the commonest cause. Particular caution is necessary in patients with pre-existing respiratory complications, e.g. COPD.
In summary, there is little evidence that at equivalent doses opioids differ markedly with respect to side-effects. However, inter-patient variability means a patient may respond more
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CPD 24: PALLIATIVE PAIN MANAGEMENT
Pfizer Healthcare Ireland are committed to supporting the continuous professional development of pharmacists in Ireland. We are delighted to be partnering with Irish Pharmacy News in order to succeed with this.
Throughout the year, Irish Pharmacy News will deliver 12 separate modules of continuous professional development, across a wide range of therapy areas. These topics are chosen to support the more common interactions with pharmacy patients, and to optimise the patient experience with retail pharmacy.
We began the 2011 programme with a section on the Gastrointestinal System. Other topics include Diabetes (Types I and II), the Cardiovascular System, Smoking Cessation, Infections, Parkinson’s Disease, Alzheimer’s Disease, Depression and others. We hope you will find value in all topics.
Pfizer’s support of this programme is the latest element in a range of activities designed to benefit retail pharmacy. Other initiatives include the Multilingual Pharmacy Tool, a tailored Medical Communications Programme, Educational Meetings and Grants, our Patient Information Pack, new pharmacy Consultation Room brochures and other patient-assist programmes including the Quit with Help programme and www.mysterypain.ie.
If you would like additional information on any of these pharmacy programmes, please contact Pfizer Healthcare Ireland on 01-4676500 and ask for the Established Products Business Unit.
favourably to one opioid than to another. As such, if a patient fails to achieve acceptable pain control or develops intolerable side-effects, an alternative opioid regime may be tried13.
OPIOID TOXICITY
Features of opioid toxicity include:
• Pinpoint pupils
• Sedation
• Depressed respiration
• Visible cyanosis
• Myoclonic jerks
• Agitation
• Confusion
• Nightmares or hallucinations
• In more severe cases – hypotension, coma and convulsions
Notably, the dose of opioid causing toxicity varies between individuals and depends on medical co-morbidities and concurrent drug therapies13.
ROLE OF THE PHARMACIST
Strong opioid analgesics, in particular morphine, are principally used in the management of pain resulting from advanced and progressive diseases. Consequently, primary care settings have witnessed a significant rise in their use2. In particular, community pharmacists are becoming more involved in the delivery of medicines advice and guidance associated with the use of such therapies.
Palliative pain management should where possible, take account of an individual patient’s needs and preferences. Patients requiring strong opioid analgesics should have the opportunity to make informed decisions about their treatment plan, in partnership with the healthcare professionals involved in their care2. Community pharmacists are ideally placed, frequently acting as an intermediary body between patients and their prescribing physicians, facilitating accurate and timely communications.
The community pharmacist should ensure that where necessary, patient understanding is supported by evidence-based verbal and written information that is tailored to meet an individual patient’s needs. The delivery of advice should be culturally appropriate and accessible to patients with additional needs such as physical, sensory or learning disabilities. Where appropriate, consenting patients may wish to have family members or carers present to help facilitate the continued delivery of essential information.
The community pharmacist will often be the healthcare professional that responds to
patient concerns, provides reassurance and actively encourages patients to comply with treatment plans. So too, the pharmacist may be the first to identify complications arising from treatment, such as the emergence of side-effects or the early warning signs of toxicity.
Evidently, the community pharmacist has a significant role to play in ensuring the effective delivery and management of palliative pain control. As such, pharmacists should ideally be well versed on the topic and capable of troubleshooting the diverse range of issues that may arise in this area.
Date of preparation: Dec 2012 EPBU/2012/125/1
References:1. NICE clinical guideline 140, May 2012. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults.
