unit 11 palliative care part 1: pain management
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Unit 11 Palliative Care Part 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. WHO Definition of Palliative Care. - PowerPoint PPT PresentationTRANSCRIPT
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 11Palliative CarePart 1: Pain Management
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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)
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Pain as a Symptom of a Treatable Condition
• Headache
• Chest pain
• Pharyngeal or retrosternal pain
• Abdominal pain
• Skin pain
• Leg pain (neuropathy)
• Generalised pain
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Skin Pain
• Herpes (Varicella) Zoster
• Post-herpetic neuralgia
• Skin infections• Impetigo and pyoderma• Folliculitis• Cellulitis
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Leg pain
• Neuropathy• HIV• Medications
• d4T, ddI
• INH
• Vitamin deficiency• Post-Herpetic neuralgia• Diabetes
• Poor circulation• Localized infections• Venous thrombosis
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Generalised Pain
• Fever
• Bed-ridden status
• Rheumatism
• Non-specific etiology
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Relationship Between Specific Treatment and Symptom Relief
Specific Treatment
Symptom Relief
Initial Diagnosis
Evolution of the illness
Death
Passage of time
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Stepped Approach to Analgesic Therapy
Mild PainMild PainNon-narcotic
Moderate PainModerate PainWeak opioids
Severe PainSevere PainStrong opioids
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Stepped Approach to Analgesic Therapy
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Stepped Approach to Analgesic Therapy
• 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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Adjuvant Pain Medications
Intestinal ColicIntestinal Colic
DrugDrug DosageDosage
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
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Adjuvant Pain Medications
Bone and Inflammatory painBone and Inflammatory pain
DrugDrug DosageDosage
Non-steroidal anti-inflammatory drugs (NSAIDs)
•Ibuprofen 200-400 mg tds
•Indomethacin 25 mg tds
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Adjuvant Pain Medications
Opioid ToxicityOpioid Toxicity
DrugDrug DosageDosage
NauseaNauseaHaloperidol
Promethazine
1.5 mg bedtime
10 mg bedtime
ConstipationConstipationStool softeners
(Colace)
Laxatives
(Sennekot, Mg Citrate)
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Adjuvant Pain Medications
Anti-Anxiety MedicationsAnti-Anxiety Medications
DrugDrug DosageDosage
Lorazepam
Hydroxyzine
Haloperidol
1 mg bedtime
25 mg tds
1.5 mg bedtime
Anti-pruriticsAnti-pruritics
Hydroxyzine
Promethazine
25 mg tds
10 mg bedtime
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
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
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