Symptom Management

Clinical Description

25.1.1. PAIN

Objective

• The objective of pain management is to ensure that the patient is free from pain at night, at rest, during the day and during movement.

Non-pharmacological

• Effective pain control requires holistic assessment of ‘Total pain’ which includes physical, psychological, social and spiritual aspects.
• This is critical for effective pain management. Issues such as positioning, management of anxiety, family support, play for children e.t.c should be attended to in the assessment and management of the patient.

Pharmacological

The treatment of long-term pain associated with life limiting illness is guided by the following principles

• Accurate diagnosis and treatment of the cause of the pain (see other chapters)
• Assessment of the severity (mild/moderate/severe) and type of pain (nociceptive/neuropathic)
• Appropriate analgesics: Non opioid, opioids and adjuvants and other modalities e.g. radiotherapy and bisphosphonates (bone pain), surgery (pathological fractures).

By the clock

• Regular analgesia is given to the patient to prevent exacerbations
• PRN medication (i.e. given as required) does not work for chronic pain

By the mouth

• Oral medication is the standard preferred for long term pain

Treatment

By the patient

• Required dose of analgesia is determined on an individual basis. This should be kept under regular review

By the ladder

The analgesic ladder

• A two- or three- step analgesic ladder enables person-centred step-wise treatment of pain. Analgesia is selected by moving up the ladder where pain increases, or where pain is not controlled, moving down the ladder e.g. if the cause of the pain is removed (e.g. following amputation or chemotherapy for a tumour).

Mild Pain - Step 1

• Paracetamol 1g 6-8 hourly (max 4g daily)

Children: 10-15-20mg/kg 8 hourly

• Or NSAIDS Aspirin 300-600mg, 6-8 hourly (max 2.4g/day)

Ibuprofen 400mg, 6-8 hourly (max 2.4 g daily), children 5-10mg/kg (max 40mg/kg/day)

Diclofenac 50 mg 8 hourly, or 100mg slow release 24 hourly, (max 150mg/daily), (not in children)

Note: use only one NSAID at any one time, avoid long term use of NSAIDs, considering contraindications e.g. renal/heart failure, PUD, pregnancy, asthmatics etc. NSAID are not to be used in children.

Moderate Pain - Step 2 (not used in children)

• Codeine phosphate 30-60mg 6-8 hourly (max 240mg daily), Always prescribe codeine with a laxative (not tramadol) e.g. Give Bisacodyl 10mg at night, unless the patient has diarrhoea
• Tramadol 50-100 mg 8 hourly (max daily dose 400mg/daily)

Notes: both codeine and tramadol can be combined with non-opiates and/or adjuvants, but not used together at the same time, or used at the same time as strong opiates e.g. morphine

Severe Pain - Step 3

Immediate release Morphine is the drug of choice for severe pain

Formulation and starting dose

• Immediate release (green) morphine 1mg/1ml - starting dose for adults 2.5-5mg, i.e. 2.5-5ml, 4 hourly
• Immediate release (red) strong morphine 10mg/1ml - starting dose for adults 2.5-5mg i.e.

0.25-0.5ml, 4 hourly

• Morphine sulphate tablets (MST) 10mg tablets - starting dose 10mg, 12 hourly

Children

• Over 1 year, dose start at 0.2mg/kg/dose, 4 hourly
• Under 1 year, dose start at 0.1mg/kg/dose, 4 hourly
• Maximum starting dose of morphine is 3mg 4 hourly, even for children larger than 15kg.

Notes:

• If a patient cannot swallow, morphine can be administered and absorbed via mucous membranes e.g. buccal (liquid) and rectal (tablets)
• If the patient no longer requires morphine, the dose should be gradually reduced to avoid withdrawal symptoms (sweating nausea, agitation)
• Pethidine is not recommended for use in chronic pain due to its short duration of action and its side effects

Titration (i.e. increasing dose to achieve pain relief)

• When pain is helped - but not totally relieved - by a starting dose of morphine the regular dose can be increased by 30-50% every 48 hours until pain is controlled.
• Where breakthrough doses are prescribed, dose increment can be calculated as follows (new dose = total regular morphine daily dose+ total breakthrough doses)
• There is no maximum dose of morphine, the correct dose is a dose which takes away the pain without causing unacceptable side effects.

Use of morphine to control ‘breakthrough pain’

• Breakthrough pain is a flare in pain of rapid onset, moderate to severe intensity and of short duration. Liquid immediate release morphine can help breakthrough pain. The dose given is equivalent to the regular four hourly dose of immediate release morphine e.g. if taking MST 10mg 12 hourly, the breakthrough dose is 20/6= 3.3mg as required (in practice give 2.5mg liquid morphine as required).
• If taking 10mg of immediate release morphine 4 hourly, the breakthrough dose = 10mg as required.

Dose conversion (changing from other opiates to or from morphine)

• Oral codeine to oral morphine, ratio 10:1, Calculation: divide total daily dose codeine dose by 10 e.g. codeine 30mg 8 hourly = total daily dose codeine 90mg = total daily dose 9mg morphine
• Oral tramadol to oral morphine, ratio 5:1 calculation: divide total daily dose tramadol by 5 e.g. 50mg every 8hrs tramadol = total daily dose 150mg = total daily dose 30mg morphine
• Oral morphine to fentanyl patch (central hospitals only) ratio 100:1 calculation: multiply total daily dose of morphine in mg by 10 to obtain the total daily dose fentanyl in microgram (μg); divide by 24 to obtain μg/hr patch strength e.g. morphine 10mg four hourly = total daily dose morphine 60mg = total daily dose 600μg fentanyl = 25μg/hour fentanyl patch

Use of morphine in special circumstances

• Immediate release morphine can be used in the management of acute pain (see other sections). When used for wound care and/or dressing changes it can be effective where administered 30 minutes -one hour before the dressing change.
• In children (e.g. for dressing change in burns) use morphine 0.2mg/kg as a single dose one hour before procedure.

Other considerations

• Monitor and manage constipation which is a common side effect of opiates e.g. attend to intake of regular fluids (water), bisacodyl 10mg at night and/or other local remedies for constipation e.g.

green mango, papaya

• Patients and their caregivers should be carefully educated on how to administer immediate release morphine as four hourly dosages.

This should be reviewed during follow up appointments.

• Doses of four hourly immediate release liquid morphine are administered at the following times each day: 6am, 10am, 2pm, 6pm and 10pm. The 2am dose can be avoided by administration of a double dose of morphine administered at 10pm.
• Opiates are controlled drugs. Prescribers are referred to the DDA

ACT for further guidance.

Complications

• Opiate toxicity (overdose) causes respiratory depression, and drowsiness (check for pinpoint pupils and muscle twitching).

Patients with renal failure (and severe jaundice) are at risk of toxicity as morphine is excreted by the kidneys. Dose frequency of morphine in confirmed or suspected renal failure should be reduced to 8 hourly.

Guidance for use of Fentanyl patches (central hospitals only)

• Fentanyl is a strong opiate used for the management of severe chronic cancer pain. It is much stronger than morphine. *Serious, life- threatening or fatal respiratory depression may occur with the use of Fentanyl. Be aware of situations which increase the risk of respiratory depression, modify dosing in patients at risk and monitor patients closely, especially on initiation or following a dose increase*
• Fentanyl is delivered via transdermal patch replaced every 3 days (72 hours), available dose of patch: 12.5ug/hourly
• Patients should only be started on a fentanyl patch where they have already had their pain controlled by morphine. For details of the conversion from morphine to fentanyl, see ‘dose conversion’ above

Adjuvant Analgesics

• ‘Adjuvant’ analgesics are drugs whose primary action is not analgesia but which can be used to control pain. They are used in situations such as neuropathic or bone pain, smooth or skeletal muscle spasms. They can be used alone, or in conjunction with step 1, 2 and 3 analgesics

Tricyclic anti-depressants: neuropathic (nerve involvement) pain,

• Amitriptyline 12.5- 25mg at night. Effect should be reviewed after 2-4 weeks. maximum dose 75mgs at night

Anti - convulsant

• Gabapentin 300mg, single dose on day one; then 300mg, 12 hourly on day two; 300mg 8 hourly from third day onwards
• Monitor for drowsiness

Corticosteroids: Reduce pain related to oedema e.g. liver capsule pain (hepatoma), sciatic nerve root compression (cervical cancer) headache (brain tumour, brain metastases)

• Dexamethasone 4-8mg, 12 hourly. Reduce by 2mg daily to the lowest effective dose children - < 1 year, 0.5-1mg 12 hourly, - 1-5 years 2mg 12 hourly, - 6-11 years 4mg 12 hourly (max 16mg/day)

Prednisolone 30mg once daily for 7 days, gradually reduce to lowest effective dose, depending on prognosis.

Note: Monitor steroid side effects: poor sleep, psychosis, dyspepsia

Complications and Referral Criteria

• Where pain persists or is complex, referral to next level of care and/or specialist palliative care providers should be considered