Unit 11 Palliative Care Part 1: Pain Management

Training on Clinical Care of HIV, AIDS and Opportunistic Infections

Unit 11Palliative CarePart 1: Pain Management


Learning Objectives

• Discuss the approach to relief of symptoms during the course of HIV infection

• Describe the stepped approach to pain control and the use of analgesics

Unit 11 Part 1: Palliative care, Pain Management Slide 2


WHO Definition of Palliative Care

• An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illnesses, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems—physical, psychological and spiritual (WHO, 2002)



Definition of Pain

• An unpleasant sensory and emotional experience often associated with actual or potential tissue damage or described in terms of such damage.

Adapted from international Association for the Study of Pain



Types of Pain

• Nociceptive• Related to tissue injury or tissue stress

• Neuropathic• Produced by nerves themselves

• Intestinal Colic• Nociceptive, but worsened by opioids

• Bone pain• May not respond to opioids



Pain as a Symptom of a Treatable Condition

• Headache

• Chest pain

• Pharyngeal or retrosternal pain

• Abdominal pain

• Skin pain

• Leg pain (neuropathy)

• Generalised pain



Causes of Headache

• Tension headache• Febrile illness

• Malaria• Sinusitis

• With focal abnormalities• Brain mass lesion like toxoplasmosis or

tuberculoma

• Acute Meningitis• Pneumococcus, Meningococcus

• Chronic Meningitis• Cryptococcus and TB



Causes of Chest Pain

• With cough or dyspnea• Pneumonia• Tuberculosis

• Substernal pain not associated with swallowing• Mediastinal adenopathy or disease

• TB, KS

• Pericarditis• TB

• Pain on swallowing• See retrosternal pain



Pharyngeal or Retrosternal Pain

• Oropharyngeal• Tonsillitis/pharyngitis• Oral candidiasis• Herpes simplex• Aphthous ulcers• Kaposi’s Sarcoma• Gingivitis

• Oesophageal• Acid reflux• Candidiasis• CMV or HSV• Aphthous ulcers• Kaposi’s Sarcoma



Abdominal Pain

• Upper GI tract• Dyspepsia• Gastric or peptic ulcer disease

• Enterocolitis/Diarrhea• Intestinal parasites• Bacterial dysentery• Clostridium difficile• TB, MOTT and CMV

• Biliary Tract Disease• Opportunistic agents of enterocolitis

• Abdominal masses• Peritonitis (TB)• Abscess• KS and lymphoma



Skin Pain

• Herpes (Varicella) Zoster

• Post-herpetic neuralgia

• Skin infections• Impetigo and pyoderma• Folliculitis• Cellulitis



Leg pain

• Neuropathy• HIV• Medications

• d4T, ddI

• INH

• Vitamin deficiency• Post-Herpetic neuralgia• Diabetes

• Poor circulation• Localized infections• Venous thrombosis



Generalised Pain

• Fever

• Bed-ridden status

• Rheumatism

• Non-specific etiology



Relationship Between Specific Treatment and Symptom Relief

Specific Treatment

Symptom Relief

Initial Diagnosis

Evolution of the illness

Death

Passage of time



Stepped Approach to Analgesic Therapy

Mild PainMild PainNon-narcotic

Moderate PainModerate PainWeak opioids

Severe PainSevere PainStrong opioids




DrugDrug DosageDosage

Mild PainMild Pain

Aspirin

Paracetamol

Ibuprofen

600 mg q 4 hrs

1 g q 4 hrs

200-400 mg q 8 hrs

Moderate PainModerate Pain

Codeine

Tramadol

60 mg q 4 hrs

50-100 mg q 4-6 hrs

Severe painSevere pain

Oral or injectable opioids, morphine Minimum 5 mg q

4 hrs, no maximum




• For moderate to severe pain, can combine a non-narcotic (aspirin, paracetemol) with an opioid

• Never combine a weak opioid (codeine) with a strong opioid (morphine)

• Morphine is underutilized, resulting in unnecessary suffering of dying patients



Morphine Use in Namibia

• Simplest formulation: MIST morphine• 15 mg/10 ml solution• N$1 per liter• Schedule 1

• Pharmacists or PMOs need to mix this• Pharmacists’ assistants cannot legally mix it (morphine powder

schedule 7)• Once mixed, pharmacists’ assistants may dispense

• Most potent formulation• 100 mg/5 ml solution• Schedule 7• Most restricted• Under control of PMO / Medical Superintendent / Pharmacist



Morphine Use in Namibia (2)

• Use the schedule 1 solution• 15 mg/10 ml

• No maximum dose of MS, titrate to effect and tolerance• Always prescribe a laxative

• Bisacodyl is effective

• Extremely effective but underused in Namibia• More advocacy is needed to promote morphine

use as part of palliative care



Adjuvant Pain Medications

Neuropathic PainNeuropathic Pain

DrugDrug DosageDosageAmitriptyline 10-25 mg at bedtime

Other anti-depressants (SSRI)* Standard doses

Carbamazapine 200 mg tds

Gabapentine* 300 – 800 mg tds

*not included in the Namibian Guidelines




Intestinal ColicIntestinal Colic


Atropine 0.02mg

Hyoscyamine 0.1mg

Phenobarbitol 16.2mg

Scopolamine 6.5mg

1 – 2 tabs

3-4 x daily

Dicyclomine 20 mg 4 x day

Hyoscyamine 0.125-0.25 mg q4h prn

Propantheline 15 mg 4 x day




Bone and Inflammatory painBone and Inflammatory pain


Non-steroidal anti-inflammatory drugs (NSAIDs)

•Ibuprofen 200-400 mg tds

•Indomethacin 25 mg tds




Opioid ToxicityOpioid Toxicity


NauseaNauseaHaloperidol

Promethazine

1.5 mg bedtime

10 mg bedtime

ConstipationConstipationStool softeners

(Colace)

Laxatives

(Sennekot, Mg Citrate)




Anti-Anxiety MedicationsAnti-Anxiety Medications


Lorazepam

Hydroxyzine

Haloperidol

1 mg bedtime

25 mg tds

1.5 mg bedtime

Anti-pruriticsAnti-pruritics

Hydroxyzine

Promethazine

25 mg tds

10 mg bedtime



Key Points

1. Relief of pain and other symptoms is part of care throughout the course of HIV disease

2. Specific treatment of illnesses and symptom relief improve the quality of life

3. In persons near the end of life, relief of symptoms is the main focus of care


laura

Iggy - this probably needs revision in the next curriculum review. The unit does not say anything about the psychological and social support that can actually alleviate pain symptoms. Just giving moral support and comfort. The unit now is very medicinal!

Date post:	01-Jan-2016
Category:	Documents
Upload:	irene-horton
View:	33 times
Download:	1 times

Unit 11 Palliative Care Part 1: Pain Management

Documents