DR.

ESTHER MUINGA
KENYA HOSPICES AND PALLIATIVE CARE ASSOCIATION
Telephone: +254-20-2729302, 0722507219
www.kehpca.org
 PALLIATIVE CARE
• Palliative care is an approach that improves
the quality of life of patients and their families
facing the problems associated with life-
threatening illness, through the prevention
and relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems,
physical, psychosocial and spiritual.

WHO, 2002
From a traditional towards a new care model:
From cure towards Care
Old concept Terminal Care
T
R
E Curative treatment Palliative Care

A
T
M Time
Death
E New Care concept
N
Curative
T
treatment
Palliative Care Post
Care

3
Lynn and Adamson, 2003
 Principles of pain management

• All medical professionals have a responsibility of

initiating immediate pain management strategies while
considering other analgesic options e.g. surgery,
chemotherapy or radiotherapy
• Patient involvement improves control
WHO cancer pain relief programme
Morphine strong opioid of choice Multidimensional assessment

WHO
Appropriate ladder Level
CANCER
Consider adjuvant drugs
PAIN RELIEF
PROGRAMME

Oral drugs

Drugs for breakthrough pain

Regular medication
 Burden of Pain
• The European Pain in Cancer survey (EPIC) is
the largest ever study into the prevalence,
treatment and impact of cancer-related pain.
» June 2007

6
 Ce
O
n=4947

p th
Ur hal
in ea er
ar /s

5%
y ig
Di pr h
zz ob t
Ab in le
do e m
m F Na ss
/v s
in
at
i u s e
al g ea r tig
/a ue/
ci sl /v
o o
d ee m
re p i t in chronic fatigue
Ch flu di
an x/d
so g
iv rd
C
ge e er
s
Dy ha in rti
c
sp ng vo ul
no e ic iti
s
ea in e/
h
/re ni oa
Fe sp pp rs
ve ira le e
t /b
r/c or re
ol y as
d/ pr t
flu ob
Tr /p l
ou ne em
Pe b le
um s
rs s w on
ia
is al
te lo
nt w
so in
re g
th
1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1%
Co
ro
ns We
ta ig a
nt ht t
in lo
Co dig ss
u es
Va ghi ti
gi ng on
na bl
ld oo
Re isc d
Th cta har
A lb ge
ch ick le
an e n e
2% 2% 2% 2% 2%

ge ing din
in o g
bo f t is
3%

w su
Pe e e
rs l ha
A
4%

is bi
ch U te ts
an nu nt
ge s ua co
in l b ug
h
bl le
ad ed
5% 5%

d i n
Ch er h g
ro a
7%

ni bits
c
fa
9%

t ig
Symptoms leading to diagnosis

Pain is the key symptom leading to cancer diagnosis followed by a lump and

ue
A
lu
m
11%

p
Pa
27%

in
S3. What symptoms lead you to see the doctor prior to your diagnosis of cancer?
Base: all who has specified cancer (n=4947)
31%

7
 MTRH paper
75% patients with cancer presenting with pain
(2012-2014)

*https://ascopubs.org/doi/10.1200/JGO.2015.000125

8
 What is pain?
• “An unpleasant sensory and emotional
experience associated with, or resembling
that associated with, actual or potential tissue
damage, IASP 2020
• Pain is a “total experience” it is not just
physical, it has psychological, spiritual, cultural
and social components. This is total pain.
Pain is “what the patient says hurts”
McCaffery & Pasero, 1999

9
 PHYSICAL

SUFFERING
PSYCHOSOCIAL EMOTIONAL

SPIRITUAL
 Causes of Pain in Lung Cancer
• skeletal metastatic disease
• pancoast tumor
• chest wall disease
Neurophysiology of Pain
 Types of pain
• Nociceptive vs neuropathic
• Acute vs chronic
• Visceral vs somatic
• Incidental pain
IASP 2019
 Nervous System
Central nervous system (CNS)
Brain and Spinal Cord

Peripheral Nervous System (PNS)

Nerve fibers go to all parts of the
body.
Send signals to the different tissues
and send signals back to the CNS
Autonomic Nervous System (PNS)
Sympathetic
Parasympathetic
Controls activity of visceral organs.
 Nociception

Cortex

Thalamus

Spinal
Cord
Receptor
Synaptic Transmission
Steps in the passage of signal from one nerve
cell to other.

Drugs are used to block the transmission of

signals from one nerve cell to other.

These drugs can effect

1.Ca2+ ion channel to prevent Ca2+ inflow

which is essential for neurotransmitter (NT)
release, e.g., the action of gabapentin.

2. Release of NT.

3. Prevent NT from binding to its receptor so

stop further transmission of the signal.
 Skin Receptors

Touch, pressure, vibration, skin stretch Nociceptors

Neuroscience. 2nd edition. Purves D, Augustine GJ, Fitzpatrick D, et al.,

editors. Sunderland (MA): Sinauer Associates; 2001.
 Mechanism: Nociceptive pain

Caused by the stimulation of intact nociceptors or sensory nerves that

mediate pain.
• Somatic pain: nociceptors in the skin, soft tissues, muscle, or bone are
stimulated, and the resulting pain usually is localized.
• Pain in the skin is often sharp, strong, burning, or throbbing.
• Pain in the muscle is often gnawing or dull.
• Pain in the bone is gnawing and dull, but can become sharp with
movement.

Tends to respond well to standard medication using WHO analgesic ladder

Ref: Harvard Medical School, 2007 19

 Mechanism: Nociceptive pain
• Visceral pain: nociceptors in internal organs
and hollow viscera organs are stimulated due
to metastasis, or to blockage, swelling,
stretching, or inflammation of the organs from
any cause. This pain is often non-localized and
causes feelings of being compressed

20
 Mechanism: Neuropathic pain
Caused by damage to nerve tissue.

Neuropathic pain is burning or like an electric shock. There

also can be numbness, tingling, or allodynia (pain resulting
from a stimulus that normally is not painful such as light
touch) in the area innervated by the injured nerves.
Effective treatment may require the addition of extra
“adjuvant” medication to standard analgesics, for
example, tricyclic antidepressants

Ref: Harvard Medical School, 2007 21

 Principles of management
• It is based on the type and cause of the pain.
• Treat the underlying cause e.g. inf.
• Should provide prompt relief.
• Should prevent recurrence.
• Patient should be pain free.
• Reassess regularly.
How to Manage Pain Effectively and
Efficiently

• Assessing Pain (PQRST)

• Treatment of Pain
• Specific drugs
• Adjuvants for Pain
• Side-effects
• Teamwork
QUESTIONS?
 PAIN MANAGEMENT

It is both by pharmacological and non

pharmacological methods.
 Why Assess Pain

• Management depends on type of pain

• Level of pain influences medications given.
• Monitor patients progress
• Patient should be pain free
 Least pain

Worst pain
imaginable
 WHO ladder

• Guides on route, timing and dose

• Three rules– by the ladder, by the clock and by mouth
• Specifies treatment according to the intensity of pain
• Referral to drug classes allow for flexibility
 WHO 3-step Ladder
3 severe
Morphine
Hydromorphone
2 moderate Methadone
Levorphanol
A / Codeine
1 mild A / Hydrocodone
Fentanyl
Oxycodone
A / Dihydrocodeine
ASA Tramadol
± Adjuvants
Paracetamol / ± Adjuvants
Acetaminophen
WHO. Geneva, 1996.
NSAID’s
± Adjuvants
 PEDIATRIC TWO STEP LADDER
Moderate to

STEP TWO
severe pain
Mild pain
STEP ONE

Strong
Non opioids
opioids
 Assessment
 Gracia is a 32 year old patient on follow up at the
CCC and on ARVs and recently diagnosed with
Lung Cancer. She comes to you complaining of
burning pain in her lower limbs for the last 2 days.
How would you classify her pain?
A. Chronic somatic pain
B. Acute neuropathic pain
C. Acute visceral pain
Suggest a suitable pharmacological treatment
option for her
 Background of opioids

• Opium – dried juice of Poppy

• Pure morphine isolated in 1806 from raw opium,
• Became a popular analgesic with introduction of hypodermic
needle.
 Indications of opioids
• WHO recommends opioids for:
- Moderate to severe pain
- Neuropathy, surgery, injuries
- Chronic malignant pain e.g tumors etc.
• chronic benign pain ( chronic non-malignant pain {CNMP})
- musculoskeletal pain
- other refractory pain conditions.
 Mild pain
• Paracetamol: Adult: 500mg-1g PO 6hrly. Max
4g/d
Children: 10-15mg/kg PO 6-8hrly.
Max 75mg/kg/d
• Ibuprofen: Adult: 400mg PO 6-8hrly. Max
1.2g/d
Children 5mg/kg PO 6-8hrly. Max
30mg/kg/d in 3-4 divided doses
 Moderate pain
• Codeine: Adult:30-60mg PO 4hrly. Max 180-
240mg/d

• Tramadol: Adult:50-100mg PO 4-6hrly. Max

400mg/d
• NB:Weak opioids are not safe for children
<12years hence strong opioids are used for
moderate to severe pain.
• Remember to prescribe laxatives unless the
patient has diarrhea.
 Severe Pain
• Morphine: given as tablets, syrup, injection.
Start at 2.5-20mg PO 4hrly depending on the
patient age, previous opiate use.
• If the patient was on step 2 analgesics, start at
10mg PO 4hrly.
• Children: less than 1 year: 0.1mg/kg (100mcg)
>1 year: 0.2-0.5mg/kg PO 4hrly.
*consult pain specialist for accurate dosing and conversion
• Ratio of morphine PO:IV is 2-3:1
• Ratio of morphine PO:SC is 2:1
• Codeine-morphine-4:1
 Administration of Morphine

• The preferred route of administration is Oral >> Parenteral >

Spinal
• Increase dose (titrate) up to Freedom of Pain
• Follow a fixed schedule for permanent pain relief
• Take into account Break-through Pain
 Side Effects

• CNS side effects

– Sedation – 1st few days of Rx.
– N & V – stimulation of emetic trigger zone, however, the
centre becomes sedated
– Delirium
• Respiratory Function
– Reduced CO2 & pH sensitivity of resp. ctr.
– Cough reflex suppression esp. by codeine
– Very rarely, pulmonary edema
 Side Effects

• Cardiovascular side effects

– Reduces heart rate,
– Histamine release – Vasodilatation (Hypotension)
• GI side effects
Numerous receptors in GI cause digestive disorders
– Slowed peristalsis – causes delayed evacuation hence
constipation. The hand that writes the morphine must also
write the laxative. Ignore this at your peril!

– Colic
 Side Effects Cont..

• Other Organ Systems

– Contracted pupils (miosis)
– Allergic Skin irritations
– Urinary retention
 Renal failure

• Affects the pharmacokinetics of other drugs including opioids

Reduce dose of morphine
Increase dose interval
Change to opioids unaffected by renal insufficiency e.g.
methadone; fentanyl
Reduce/stop NSAID
 Breakthrough pain
• A transitory exacerbation of pain that occurs
in a background of otherwise stable and
controlled pain. NB: it does not occur when
the patient is almost due for his next dose of
treatment.
• 10% of the total daily dose can be given hourly
between doses.
 Alternatives to Morphine

Morphine is the opioid of choice

• If intolerant try:
– Other opioids e.g methadone; fentanyl; hydromorphone;
oxycodone etc
– For Bone pain – Radioactive metals eg Strontium;
bisphosphates
– Non drug treatment
– Spinal analgesia
 Methadone

• Good oral efficacy

• Extended duration of action
• Ability to suppress withdrawal symptoms in heroine addicts
• Pharmacologic profile resembles morphine
• Accumulation occurs in prolonged use
 Fentanyl

• Synthetic opioid related to meperidine

• Mainly for induction of anesthesia (inj.)
• Short acting
• Transdermal patches: for chronic pain for Pts requiring opioid
analgesics
– Patches can give relief for 72 Hrs.
– 6 days to achieve steady state levels
– Not to be used in acute pain
 Tolerance
• Defn: a physiological state characterized by a
decrease in the effects of a drug e.g.
analgesia, nausea, sedation with chronic
administration.
• Tolerance to analgesia may require you to
increase the drug dosage. This could mean
that the disease is progressing.
• Typically never occurs to constipation.
 Physical dependence
• Defn: physiological adaptation of the body to
the presence of an opioid. It is defined by the
development of withdrawal symptoms when
opioids are discontinued, when the dose is
reduced abruptly or when an antagonist is
administered.
 Addiction

• Prescribed appropriately, according to the

WHO ladder, after proper pain assessment,
addiction does not occur, (Hospice Foundation
of America, 2007).
• < 1 % reported addiction in patients using
opioids for short term acute pain
management, (Joranson et al, 2005).
• Addiction is compulsive use of drugs for non
medical reasons: it characterized by a craving
for mood altering drug effects and not pain
relief.
• Unlike dependence and tolerance, addiction is
characterized by dysfunctional behaviour.
 Adjuvant drugs

• The health worker is the most powerful adjuvant.

• Describes drugs whose primary indication is not pain
killing BUT has some analgesic role in some pain
conditions
• Enhances pain relief, treats pain refractory to
opioids, reduced dose of opioids = reduced side
effects– co-analgesic
• Multiple classes
 Adjuvants

One adjuvant at a time, targeted to the specific

symptom
1. Tricyclic antidepressants (amitriptyline,
nortriptyline, desipramine, venlafaxine) for pain
described as “constant burning pain”
2. Anticonvulsants (Gabapentin, valproate,
carbamazepine, clonazepam) for pain described as
“shooting, stabbing, electric shock pain”
3. Corticosteroids are useful for bone pain, increased
ICP, nerve compression.
4. Benzodiazepines, baclofen for muscle spasm.
 Role of Radiotherapy?
• Role of DXT
• Bisphosphonates- zolendronic acid
• Cessation of smoking
Non-pharmacological Pain Management
Therapies

They do not involve taking medicines, but work along with

conventional medicines. Have been used to help with pain and
healing from the very beginning of time.
a) Physical- massage, exercise, warm packs.
b) Psychological- counseling, relaxation therapies, distraction,
pain education, meditation.
c) Social- help the patient resolve social conflicts through legal
support, financial support.
d) Spiritual- religious counseling and prayer.
 Case study: Rita
• 40 year old widow who felt a painless chest
mass 3 years ago
• She has since had progressive increase in the
size of the mass and is now very painful.
• She had been offered a excision surgery but
declined because she feared post-operative
pain and death
 Case study: Rita

• How will you assess her pain?

• What other concerns may be contributing to
her pain?
• If Rita was on morphine 10mg 4 hourly, what
changes would need to be made to control
her pain?
 YOUR ROLE IN PAIN ASSESSMENT
 Identify patients in pain
 Look at the patient for any signs of pain
 Ask a few questions about pain e.g. where is the
pain? When did the pain start?
 Identify other aspects of pain
 Find out if they are taking medicines as
instructed
 Assist/ educate patients and relatives on pain
 Monitor the pain
 Refer as appropriate
 Take home messages
• Pain not reported does not mean pain not
experienced.
• Psychological interventions are an integral
component of pain management.
• Always re assess your patient with every visit.
• Correct use of morphine is more likely to prolong
the patient’s life because he is more rested and
pain free.
• The hand that prescribes morphine should also
prescribe a laxative.
 And most importantly …

11/1/2021
 References
• Simmons, C. P., Macleod, N., & Laird, B. J. (2012). Clinical
management of pain in advanced lung cancer. Clinical
Medicine Insights. Oncology, 6, 331–346.
https://doi.org/10.4137/CMO.S8360
• https://lungcancer.net/symptoms/pain
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450869/
• DOI: 10.1200/JGO.2015.000125 Journal of Global Oncology 1,
no. 1 (October 01, 2015) 23-29.
• https://bmcfampract.biomedcentral.com/articles/10.1186/s1
2875-018-0783-9
• Beating Pain Book - APCA