Treatment Treatment in Palliative Carein Palliative Care

Problems Problems

Symptom managementSymptom management

evaluation evaluation individualized treatmentindividualized treatment explanationexplanation supervisionsupervision attention to detailattention to detail

Main problems Main problems

PainPain ConstipationConstipation Lack of appetiteLack of appetite Loss of weightLoss of weight SleepnessnessSleepnessness AnxietyAnxiety Nausea and vomitingNausea and vomiting PowerlessnessPowerlessness DyspnoeDyspnoe

Objaw Bedard 1991N=952 (%)

Coyle 1990 N=90 (%)

Ból 12-30 34

Duszność 9 28

Nudności 16 13

Wymioty 16 -

Bezsenność 5 57

Zaburzenia orientacji 4 28

Zmęczenie - 52

Anorexia 14 6

Nietrzymanie moczu 4 6

Główne problemy lecznicze

Pain is Pain is

what the patient says hurtswhat the patient says hurts

Total painTotal pain

Physical pain Physical pain basal disease, coexisting illnesses, results basal disease, coexisting illnesses, results

of treatmentof treatment Psychological sufferingPsychological suffering

anxiety, depressionanxiety, depression Spiritual suffering Spiritual suffering

existential and religious problems, existential and religious problems, DAME CECILY DAME CECILY

SAUNDERS SAUNDERS

PAINPAIN

PHYSICAL

PSYCHOLOGICAL SOCIAL

SPIRITUAL

TOTAL PAIN

Saunders 1967

Pain scalesPain scales Visual-analog scaleVisual-analog scale

Numeric Rate scale NRSNumeric Rate scale NRS

0 100 10Lack of Pain Unburreable PainLack of Pain Unburreable Pain

1 101 10Brak ulgi w dolegliwościach całkowita ulgaBrak ulgi w dolegliwościach całkowita ulga

1 2 3 4 5 6 7 8 9 10

Pain Pain

ACUTE - CHRONICACUTE - CHRONIC

NOCICEPTIVE NOCICEPTIVE

NEUROPATHICNEUROPATHIC

PSYCHOLOGICALPSYCHOLOGICAL

Nociceptive pain Nociceptive pain

STIMULATION OF NERVE ENDINGSSTIMULATION OF NERVE ENDINGS

visceral ( colic, migraine, cancer)visceral ( colic, migraine, cancer) somatic ( cancer, infection, tension somatic ( cancer, infection, tension

headache, cramp, bone)headache, cramp, bone) muscles tensionmuscles tension

Neuropathic painNeuropathic pain

nerve compressionnerve compression nerve injurynerve injury

* peripheral (de-afferentation)* peripheral (de-afferentation) - Somatic (peripheral neuropathy, phantom)- Somatic (peripheral neuropathy, phantom)

- Visceral ( infiltration of para-aortic visceral - Visceral ( infiltration of para-aortic visceral nerves) nerves)

* central * central ( poststroke, spinal cord compression)( poststroke, spinal cord compression) *sympathetically maintained *sympathetically maintained ( causalgia)( causalgia)

Analgetic Ladder Analgetic Ladder WHO 1986WHO 1986

II0 0 non-opioids + adjuvants non-opioids + adjuvants

IIII00 weak opioids + non-opioids weak opioids + non-opioids + adjuvants + adjuvants

IIIIII0 0 strong opioids + non-opioids strong opioids + non-opioids + adjuvants + adjuvants

Principles of analgesic usePrinciples of analgesic use

By the mouthBy the mouth By the clockBy the clock By the ladderBy the ladder Individual treatmentIndividual treatment

SupervisionSupervision Adjuvant drugsAdjuvant drugs

But...But...

Chronic pain needs to be treated by Chronic pain needs to be treated by slow acting medicineslow acting medicine PERSISTANTLY... PERSISTANTLY...

Breakthrough pain ( predictable , non-Breakthrough pain ( predictable , non-predictable, pain of the end dose) needs predictable, pain of the end dose) needs using occasionally short acting using occasionally short acting medicine.medicine.

Non opioidsNon opioids

ParacetamolParacetamol Non- steroid Antiinflamatory Drugs (COX–1)Non- steroid Antiinflamatory Drugs (COX–1)

IbuprofenIbuprofen DiclofenacDiclofenac KetoprofenKetoprofen Piroxicam etcPiroxicam etc

Non- steroid Antiinflamatory Drugs (COX–2) Non- steroid Antiinflamatory Drugs (COX–2) Acetylsalicylic acidAcetylsalicylic acid

Weak opiois Weak opiois ( II( II00 WHO) WHO)

Tramadol 1/5Tramadol 1/5 Codein 1/10Codein 1/10 Dihydrocodein 1/10Dihydrocodein 1/10 Oxycodon 1,5 / 1Oxycodon 1,5 / 1 Dextropropoxyphen Dextropropoxyphen

Pentazocin – Pentazocin – DO NOT USE !!!DO NOT USE !!!

TramadolTramadol

caps 50mg, tabl. forte caps 50mg, tabl. forte 100mg, 100mg,

SR-tabl. –retard- 150, 200mgSR-tabl. –retard- 150, 200mg guttae 1g/10ml (1ml=40gtt.) guttae 1g/10ml (1ml=40gtt.) agonist of agonist of μμ -, -,δδ-, -, κκ- receptor - receptor presynaptic bloker of rec. presynaptic bloker of rec. MAO MAO convulsions threshold is convulsions threshold is lowered lowered

Pentazocin ( Fortral)Pentazocin ( Fortral)

Partial agonist Partial agonist μμ receptor receptor Agonist Agonist κ κ receptorreceptor Pure antagonist Pure antagonist δ δ receptorreceptor Short acting 2-3 hShort acting 2-3 h Psychotomimetic effectsPsychotomimetic effects

DO NOT USE IN CHRONIC PAINDO NOT USE IN CHRONIC PAIN

Strong opioids Strong opioids IIIIII00 WHO WHO

Morphine hydrochloride ( substance, Sevredol, Morphine hydrochloride ( substance, Sevredol, Vendal,)Vendal,)

Morphine sulphate (Doltard, MST-Continuous, Morphine sulphate (Doltard, MST-Continuous, M-Eslon, Vendal, ) 1/1 M-Eslon, Vendal, ) 1/1

Fentanyl ( Durogesic TTS) 150/1Fentanyl ( Durogesic TTS) 150/1 Buprenorphine (Bunondol, Transtec TTS) 60/1Buprenorphine (Bunondol, Transtec TTS) 60/1 Methadone 5-10/1Methadone 5-10/1 Diamorfina ( heroin) 2/1Diamorfina ( heroin) 2/1 Dextromoramid (Palfium) 2/1Dextromoramid (Palfium) 2/1 Pethidine (Dolargan) 1/8 – DO NOT USE!!!Pethidine (Dolargan) 1/8 – DO NOT USE!!!

MorphineMorphine

Pure agonist of Pure agonist of receptor receptor Without ceiling-effectWithout ceiling-effect M6G is 10-20x M6G is 10-20x , M3G (toxic), , M3G (toxic), First dose 30 mg/24h ( 15mg/24h )First dose 30 mg/24h ( 15mg/24h ) Dose is arised 50% if ineffective Dose is arised 50% if ineffective 10% of Codein is metabolised to M6G10% of Codein is metabolised to M6G

MorphineMorphine

Morphine hydrochloride Morphine hydrochloride SubstanceSubstance Sevredol tabl. 10- 20mg – Sevredol tabl. 10- 20mg – short actingshort acting VendalVendal

Morphinum sulphate 10,30,60,100mgMorphinum sulphate 10,30,60,100mg M-EslonM-Eslon MST-ContinuousMST-Continuous DoltardDoltard Kapanol Kapanol

Rp.Rp.

Morphini hydrochlorici 4,0Morphini hydrochlorici 4,0Aquae destillatae ad 400,0 mlAquae destillatae ad 400,0 ml

M.f. SolutioM.f. SolutioD.s. ½ ml q4h D.s. ½ ml q4h

660000, 10, 100000, 14, 140000, 18, 180000, 22, 220000, ( 2, ( 20000 ) )

FentanylFentanyl

Pure agonist Pure agonist Fentanyl is 150 x Fentanyl is 150 x than MF than MF Lipophilic ( peripheral side effects are Lipophilic ( peripheral side effects are

not so strong as MF) not so strong as MF)

PethidinePethidine

Agonist Agonist Action time – 2-3 hAction time – 2-3 h Ceiling effect 600mg/24hCeiling effect 600mg/24h Toxic methabolite– norpethidine Toxic methabolite– norpethidine Siede effects: myoclonus, dysphoria,Siede effects: myoclonus, dysphoria, Indications: acute pain, not use longer than 48 h, Indications: acute pain, not use longer than 48 h, Contraidications: renal failureContraidications: renal failure

SensitizationSensitization

PERIPHERAL PERIPHERAL activation of „sleeping receptors”activation of „sleeping receptors” „„inflammatory soup” inflammatory soup”

CENTRAL – activation of the NMDA CENTRAL – activation of the NMDA receptor-channel complexreceptor-channel complex

Wind-up Wind-up

Chronic irritation of C-fibers , which Chronic irritation of C-fibers , which are proliferated in posterior horns of are proliferated in posterior horns of medullae spinalis and are responsible medullae spinalis and are responsible for potencialization of the impulses for potencialization of the impulses ( allodynia)( allodynia)

MethadoneMethadone

Agonist Agonist -receptor and -receptor and -receptor-receptor Racemic forms: L- i D Racemic forms: L- i D NMDA – receptor antagonist NMDA – receptor antagonist The plasma halflife ranges 8-80 hThe plasma halflife ranges 8-80 h Bioavailibility 80% (parenteral)Bioavailibility 80% (parenteral) LipophilicLipophilic Eliminated by alimentary tract in 80% (in Eliminated by alimentary tract in 80% (in

renal failure may be used)renal failure may be used) 5-10 x 5-10 x than MF, 3-5mg start dose than MF, 3-5mg start dose

Receptor NMDAReceptor NMDA

Nmda.gif

Opioid Rotation Opioid Rotation

Non effective, toxicNon effective, toxic Because- of different types of opioid Because- of different types of opioid

receptors receptors Differences in pharmacocinetics and Differences in pharmacocinetics and

methabolizm of opioidsmethabolizm of opioids Be careful in equivalent doseBe careful in equivalent dose supports of tolerance – metadon ma supports of tolerance – metadon ma

większą wewnętrzną aktywność niż MFwiększą wewnętrzną aktywność niż MF

Muscle spasmMuscle spasm

MiorelaxantsMiorelaxants Baclofen (GABA- agonist) tabl. 10 i 25mgBaclofen (GABA- agonist) tabl. 10 i 25mg

3 x 5-10 mg 3 x 5-10 mg TyzanidineTyzanidine

Benzodiazepins Benzodiazepins Midazolam 7,5 – 15 mg p.o. Midazolam 7,5 – 15 mg p.o. Clonazepam 0,5 mg /nocteClonazepam 0,5 mg /nocte

Diazepam 5-20 mg p.o. Diazepam 5-20 mg p.o.

Adverse effects of opioidsAdverse effects of opioids

Constipation 100%Constipation 100% Nausea and vomiting – 50%Nausea and vomiting – 50% Drowsiness – 100% Drowsiness – 100% unsteadiness, confusion – initialunsteadiness, confusion – initial Stop urination – be careful !!Stop urination – be careful !! Central depressant effectsCentral depressant effects Psychological dependence Psychological dependence Physical dependence Physical dependence Occasional – dry mouth, inflammation of mouth, Occasional – dry mouth, inflammation of mouth,

candidiasis, sweating, myoclonus candidiasis, sweating, myoclonus

Never say Never say

I have tried everything...I have tried everything...

There is nothing more I can There is nothing more I can do ...do ...