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You can control pain
Module 9
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Learning objectives
■ Describe the 3 steps of the analgesic ladder■ Give examples of drugs from each step of
the ladder■ Explain the use of adjuvant drugs
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Pain Assessment
■ careful evaluation– remember ‘total pain’– scales / tools / charts
■ detailed history■ examination■ appropriate investigations
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Total pain
Physical
Social
Emotional
Spiritual
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WHO
Comprehensive Cancer Control Programme
■ prevention ■ early detection and curative treatment■ cancer pain relief and palliative care
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Pain management
■ by the ladder– stepwise progression
■ by the clock– regular prescribing
■ by the mouth– oral route preferred
■ by the individualWHO 1986 Cancer Pain Relief
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By the ladder
1
2
3
Pain persisting or increasing
Non-opioid Adjuvant
Pain persisting or increasing
Opioid for mild to moderate pain Non-opioid Adjuvant
Pain persisting or increasing
Opioid for moderate to severe pain Non-opioid Adjuvant
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By the clock
PAIN
SIDE EFFECTS: Drowsiness
PRNToo HighToo High By the clockMorphine dose
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By the mouth
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By the individual
■ hepatocellular carcinoma
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Pain management; non opioids
■ paracetamol■ NSAID’S
– diclofenac 50mg TDS– inflammatory based pain
■ bone pain
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Pain management; opioids
Step 2 analgesics / weak opioids■ codeine■ dextropropoxyphene■ tramadol
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Pain management; opioids
Step 3 analgesics; strong opioids■ morphine■ fentanyl
■ nb don’t use pethidine or pentazocine
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Pain management
Adjuvant analgesics■ severe swelling or inflammation■ nerve damage (neuropathic pain)■ muscle spasm (skeletal muscle)■ abdominal cramps (smooth muscle)
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Pain management; adjuvants
■ severe swelling or inflammation– steroids
■ nerve damage (neuropathic pain)– tricyclics; amitriptylline, imipramine– anticonvulsants; sodium valropate, clonazepam
■ muscle spasm (skeletal muscle)– diazepam, lorazepam
■ abdominal cramps (smooth muscle)– hyoscine butylbromide
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Pain management
severe swelling or inflammation■ hepatocellular carcinoma
– liver capsule stretch
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Pain management; adjuvants
■ steroids– dexamethasone 8-16mg po / parenteral
■ swelling / oedema– raised intra-cranial pressure– nerve compression– visceral stretch
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Pain management
nerve damage (neuropathic pain)■ herpes zoster
– burning neuropathic pain
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Pain management; adjuvants
■ anti-depressants– amitriptyline (low dose) 10-25mg po– impramine
■ neuropathic pain■ potentiate descending inhibitory pathways
– block pre-synaptic reuptake noradrenaline and 5HT3
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Pain management; adjuvants
■ anti-convulsants– sodium valproate 200-600mg– gabapentin 300-2400mg– clonazepam 0.5-2mg– (carbamazepine)
■ neuropathic pain■ membrane stabilisers
– may prevent abnormal impulse generation
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Pain management
muscle spasm (skeletal muscle)■ rectal cancer
– tenesmus
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Pain management
abdominal cramps (smooth muscle)■ bowel obstruction
– cramping abdominal pain
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Pain management; adjuvants
■ muscle relaxants– smooth muscle spasm
■ buscopan■ dicyclomine
– skeletal muscle spasm■ diazepam■ baclofen■ tizanidine
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These resources are developed as part of the THET multi-country project whose goal is to strengthen and integrate palliative care into national health systems through a public health primary care approach– Acknowledgement given to Cairdeas International
Palliative Care Trust and MPCU for their preparation and adaptation
– part of the teaching materials for the Palliative Care Toolkit training with modules as per the Training Manual
– can be used as basic PC presentations when facilitators are encouraged to adapt and make contextual