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Palliative care 4- Pain

Palliative Care PART – 4

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question: Last time we covered some important aspects of pain management in palliative care.  

1. Concept of WHO analgesic ladder. 2. How to use most commonly available pain medicines in adequate doses and schedule i.e. paracetamol, NSAIDs, Tramadol. 3. Misconceptions related to side effects of pain medicines. 4. Role of NSAIDs in pain related to bone metastases. Also bisphosphonates or denosumab.

2. How to use most commonly available pain medicines in adequate doses and schedule i.e. paracetamol, NSAIDs, Tramadol. 3. Misconceptions related to side effects of pain medicines. 4. Role of NSAIDs in pain related to bone metastases. Also bisphosphonates or denosumab.

These points are very important for our readers. In fact, one very senior General Practitioner did call to express how the series is helpful to him and his colleagues in taking care of such patients.

Ans: I am glad to know that it is making a difference in lives of patients and helping my colleague doctors. Apart from above points highlighted by you, we also covered another very important aspect of pain management.

Que: Which point did I miss?

Ans: Setting the expectations! This is equally important, same as knowledge of medicines. Especially in advance cancer, or in chronic pain patients. You have to clarify from the outset that complete pain relief is unlikely without the cancer going away. But you will have significant relief, which will allow you to sleep, eat and have fairly normal routine activities, without interference due to pain. And that he will not “suffer” due to pain. Many patients are seeking complete pain relief. And hence they are dissatisfied, keep changing medicines and doctors. Or end up with excess medicines and side effects.

Que: Thank you. Yes I did miss this important point from out discussion last time.

Ans: Now let us talk about role of other adjunct measures and medicines in pain control, before we go to morphine. Many additional measures can help improve pain control.

  1. Sedation i.e. sleeping pills should NOT be prescribed for pain control. This is unfortunately the most commonly used additional medicine when pain is not controlled well. Even relatives come and request to give sleeping pills as patient is suffering from pain. When you prescribe sedative, patient may be sleepy and may not be able to complaint about pain, or may even be very sedated. And yet he/she is in a lot of pain. Patient is now still in same amount of pain, but unable to express, or ask for pain medicines. This is actually worse! Most of the patients will sleep well once pain is controlled well.
  2. Neuropathic pain: pain due to pressure on nerves or involvement of nerves by cancer, or nerve roots from spinal cord. Neuropathic pain may also result as a side effect of some chemotherapymedicines e.g. vincristine, cisplatin, paclitaxel, bortezomib. This is similar to diabetic neuropathy, but frequently much more severe. This pain is not controlled well by traditional pain medicines alone, including even opioids. They need medicines like pregabalin, gabapentin in addition. Antidepressants like duloxetine, amitryptiline are also widely used to treat neuropathic pain. They provide additional antidepressant effect in patients who are in depression from chronic pain or cancer. Local application like skin irritants are helpful in reducing pain as well, such as capsaicin cream, or our good old “balm”. Applying balm for headache is also same concept.

These pains are one of the worse pains, sometimes described as shooting pain, radiating pain by the patients. One very important aspect of managing these pains is PROCEDURES, by pain specialists, frequently known as “NERVE BLOCK”. This involves identifying the nerve or nerve root or plexus involved and then injecting it with medicine, such as xylocaine, alcohol, phenol. Or ablation by Radiofrequency. Such procedures are extremely effective in many patients, in expert hands. And allow patients to reduce pain medicines by up to 100%. Yes few patients will even come off all pain medicines. Patients who are on high doses of morphine like 200 mg per day also may come off medicine completely. Such procedures are done as outpatient, need minimal infrastructure such as IITV, USG or CT scan for radiological guidance, and mainly a trained expert. Many anesthesiologists work as pain specialists in our region. This is a fairly costly procedure however, but there are centers providing this at highly subsidized rates. Pancreas cancer is a common example where celiac plexus block can render patient pain free for several months. Same is true for brachial plexus for arm pain, spinal root related pain, head and neck cancers, intercostal block etc.

December 14th 2020. 

Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com

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