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So today's talk is about pain management in palliative care. So like with anything, the first thing you need to do with pain is assess it. You want to know if it's acute or chronic and like everything you'll follow a structure. So you all must be familiar with Socrates and that's basically the side onset characteristic radiation, any associated symptoms, the timing, any exacerbating or relieving factors and the severity, then you also want to find out if they've experienced such pain before, if they have that would be useful in trying to um uh make a management plan, you can see the response to previous treatments, previous medications. And if that has worked for such kind of a pain in the past, are they able to manage the basic functions? So, are they able to eat, drink, sleep, mobilize and double check? What is stopping them? Is it the pain or is it something else like shortness of breath, et cetera? Uh most importantly, you want to know the ideas, concerns expectations, especially for someone who's, you know, palliative. Are they struggling with issues such as nausea or constipation? Because whatever allergies that you add to that will have an effect. So you really do want to know what they want to get out of this and then going a bit further, you want to know the impacts of this pain on the psychological and social factors. Now, it's fairly straightforward to assess pain in someone who's got capacity, who can articulate what it is where it is. But quite often you'll get to, you'll have to assess pain on someone with impaired cognition. As always, you're going to involve the patient allow plenty of time and minimize destructions. Um If you can be in an environment that they're comfortable with or any hearing aids or visual aids that they need, that can help collateral form, carers, family staff, anyone who's familiar with the patient's baseline and why they think they're in pain and what signs is the patient showing focus on non verbal cues? Are they more agitated? Their posture? Are they leaning to one side or the other? Have they had a fall? Have they heard something? Is there a fracture? Uh visual illustrations if it's applicable and exclude any other sources of distress? So do they have an infection? Are they constipated or is it pain that's actually causing all this agitation? Uh All of you must be familiar with the wh O analgesic ladder, we'll just quickly run through it. So step one, you'd give a normal opioid. So paracetamol nsaids plus minus any adju and those could be things like antidepressants, steroids, anticonvulsants you can add them at any step uh as you progress through this ladder. So step two will be weak opioids. Uh codeine dihydrocodeine traMADol uh and then step three are strong opioids. Always consider antiemetics or laxatives. Uh when you're uh prescribing opioids either in the acute or chronic setting, uh just to get a bit, get started. So here's a question. We've got Mister Jones who has metastatic lung cancer. Now, he's not managing at home and he's admitted to hospital for pain. He is taking regular paracetamol only. That's his most recent recent bloods. Which option of pain relief do you think is more suitable for him? Take a minute or so and then just pop your answers in the chart? Ok. OK. II just realized I can't see the chart. So I'm gonna Oh yeah. Mhm Yeah. A bit of a shy crowd. So I think that's all right. That's fine. We can just walk through the question. So, um fine. So you'd so a few things to consider in this question one is they've got metastatic lung cancer. So you'd want to give them adequate pain relief uh from the blood, you can make out that they've got de deranged urea and creatinine. So that in the case, they've got uh renal uh dysfunction and probably at the value of the urine creatinine, they've got severe renal impairment in cases of severe renal impairment. You'd you, you'd consider fentaNYL buprenorphine or a fentaNYL. If you look at all the options here. FentaNYL is the only one, only appropriate option from the list given. And primarily you use fentaNYL or buprenorphine because they're met uh metabolized and excreted by the liver. The other options we can walk through them. So, traMADol is, you know, a weak opioid. As I said, they've got metastatic lung cancer. You'd want to give them good and adequate pain relief. So you'd move on to the strong opioid. You can carry on regular paracetamol. Morphine and oxyCODONE are not indicated in severe renal impairment. So you try and avoid them. Uh paracetamol, as we said, is not controlling his pain and nsaids, uh or you can give them his blood in the case he's got severe renal impairment. So you try to avoid it if you can. So that leads us to fentaNYL as the option. All right. A note on nsaids. So you want to take into account the individual risk factors. When you're prescribing nonsteroidals. If they are indicated of an appropriate, you want to start with the lowest effective dose for the patient, avoid in patients who got severe heart failure, severe renal failure or at risk of gi side effects. And if you're prescribing nsaids, think about PPIs for people whose BP is consistently above 140 by 90 you'd avoid high dose ibuprofen and oxy and uh diclofenac and high dose Ibuprofen are contraindicated in people with ischemic heart disease, cerebrovascular disease and peripheral arterial disease in patients who've got severe renal failure, you can see nsaids prescribed. So it's not a definite no, but you do need to weigh up the risks and benefits and discuss it with sort of the consultant and the patient. And if they're happy, you can sort of try them at a low dose. All right, conversions. So this is something you all must be familiar with to convert oral morphine to subcut morphine. You divide it by two to convert oral morphine to a subcardial morphine. You divide it by three and to convert oral morphine to um oral oxyCODONE, you divide it by 1.5. These are the main calculations that you should sort of know that they might ask you for. In addition to convert all oxyCODONE to suba diamorphine, you divide it by 1.5 and approximately 10 mg of oral oxyCODONE is 6.6 mg IV slash subcut oxyCODONE. But the main things you sort of need to know are how to convert oral morphine to sub gut morphine, sub gutor or oral oxyCODONE. Those are the most common sort of things you'd be asked to do. So, key points for breakthrough pain, you'd want to give 1/6 of the total daily dose of morphine. You start patients on regular oral modified release, morphine plus a breakthrough prescription. Yeah, the dose depends on whether the patient is opioid knive. Um And depending on that you can start at a lower or higher dose. If you need to titrate the dose, you titrate it about by about 30% of the existing dose. Sometimes people do it 50% but 30 to 50% is the range you aim for not more because you don't want to, you want to avoid toxicity and gradually build them up. Mild to moderate renal impairment. Consider oxyCODONE severe renal impairment, alfentanyl buprenorphine or fentaNYL patches just so you have and figure in your mind, morphine salt, 12 mg is equal to buprenorphine five patch and morphine salt, 30 mg is equal to fentaNYL. 12 patch patches are usually used for stable or chronic pain. Um So if they've come in with acute pain, you may need to start them on an fentaNYL or oxyCODONE depending on the renal function. And you can always add a patch but may not see any immediate effect with it. And like I mentioned before, laxatives, um especially if someone's, you're clerking someone and they've come on an acute admission. Uh and the elderly, you can always prescribe laxatives, spr N if it's appropriate. And that way, even if it's missed during ward rounds, at least the nurses know that there's a prescription and they can start giving it and when they escalate, you know, at least some things have been tried. Syringe driver. So usually you consider this when a patient is not able to take the oral medication and that could be for a range of different reasons. It could be nausea, vomiting, dysphasia, with reduced consciousness, inter obstruction, significant tablet burden. You can also consider it if they're really agitated or restless or they've got a lot of secretions and they just unable to take um tablets. Diamorphine hydrochloride is the the recommended choice. Um And that's because it's got high solubility and you can give larger doses um in a smaller volume. Uh But in saying that you'd either see diamorphine or morphine used in the syringe driver. You can continue fentaNYL and buprenorphine patches in the dying patient. But quite often, what is missed is that people forget to change the patches regularly. For example, if they're on end of life care and they've got anticipator and you stop all the medications, they would stop the patches, but they still have one on so you can carry it on. It's absolutely fine, but just make sure you have the prescription there so they can change it regularly. And also ensure if you're trying to change the dose of opioids, you account for the dose in the patch. All right, I've got another question. So we've got a 72 year old female who's got a background of metastatic breast cancer. She can't take her oral medication and we've made a decision to set up a syringe driver. She takes modified release oral morphine, 70 mg twice a day. In addition, she's also been requiring 40 mg of or morphine P RN doses. What dose of diamorphine should be prescribed over 24 hours and it so to convert oral morphine to diamorphine, you need to divide by three. So if you just cal calculate total dose of morphine, you take it and divide by three, I'll give it a minute. Um and you can pop your chat, it, pop your answers in the chat and regardless we'll discuss the answer in a minute. Sure. So I can't see. Yeah. Oh, there we go. 6180 by three. That's right. So you guys have got the right answer. So is the total dose is 1 80 mg, you divide it by three and you get, you get the total uh sub dimorph dose, which is 60. In this case right now, there are different kinds of pain uh that patients can experience if they're experiencing neuropathic pain. Quite commonly, the agents you think of might be pregabalin, gabapentin and amitriptyline. And those are the ones we commonly use for neuropathic pain. So if you let's talk about pregabalin first, you'd usually start at 1 50 mg once a day in 2 to 3 divided doses. Um So about 75 mg twice a day, you can start at a lower dose than 150 depending on the patient maximum you can give is 600 mg once a day. You need to trial it for at least four weeks before deciding it's not effective for the patient. Um Or if they're having side effects. And if you need to stop it, you gradually discontinue it over a minimum of a week. Important to note is that there is a renal dose in case of impairment and it does substantially differ. So, for example, if someone's creatinine clearance is less than 15, the initial daily dose is 25 and the maximum dose is 75 mg, which is in contrast to a person with normal renal function who could take up to 600 there are loads of side effects, but some of the common ones to keep in mind, uh diplopia, dry mouth, cervical spasm, headache, lethargy, or decreased libido and certain areas of caution with any sort of neuropathic agent. You should kind of uh if you're prescribing it in the elderly, you should make sure that it is generally indicated and they could benefit from it. There is a false risk. So you need to take that into account, a small, small risk of suicide and a history of uh and if they've got a history of substance abuse because it can be addictive. So you need to take those things into account when you decide to prescribe it. Another agent is gabapentin. So your initial dose will be 300 mg once a day. Now, phospha is slow, that's how quickly you titrate it. Um In someone who's younger and adult, you can titrate it faster and that just means increasing the dose of every day. Uh And if, um, and starting them on a higher dose, you could start them on 300 and you titrate it a bit slower if the elderly or frail or they previously tried the drug and had side effects at high at a higher dose. So you can restart it at a lower dose and, uh, slowly titrate them. The maximum is 3.6 g a day. And again, in this case, you'd consider to try it for 3 to 8 weeks. But the important thing is to note is that you want at least two weeks where you're given the maximum tolerated dose. So they can only tolerate 300 that's fine. But you want to give them two weeks where they've had 300 mg and see if it's made any impact. And if not, or if they've got side effects, you'd gradually discontinue it over um at least a week. Again, like with pregabalin, there's a renal dose in case of impairment. And you can refer to the B NFI think they clearly document how much to give uh again, multiple side effects. But some of the common ones to know is gingivitis, viral infections, otitis media, twitching, nystagmus, acne nervousness and again, like with pregabalin, this is cautioned in those who are at risk of suicide. The other agent that we commonly use in neuropathic pain is amitriptyline here, you'd start at about twe 10 to 25 mg once a day and the usual maintenance dose is about 25 to 75. So you consider trialing it for 6 to 8 weeks and again, give at least two weeks with the maximum tolerated dose and see if it had any impact. If it's not tolerated, it's a bit longer to discontinue it. So you want to gradually taper it off over four weeks uh to avoid symptoms such as nausea, headaches, dizziness and some of the common side effects to know for amitriptyline is anticholinergic syndrome, drowsiness and QT interval, prolongation. So other sort of pain that they can have is headaches due to raise in the cranial pressure. So you tried them with dexamethasone 8 to 60 mg once a day and you'd consider gastroprotection, uh like you would most or any steroid. Now, dexamethasone is a drug that's used for other things in palliative care. Can you guys think of any other sort of uh indications for commencing dexamethasone in palliative care? Just pop it in the chart chart? Oh, well, that kind of gives the answer. Ok. So some of the reasons to try dexamethasone in palliative care would be if they've got pain secondary to nerve compressions, it's used in case of nausea and vomiting and it is quite effective. Uh dyspnea due to partial obstruction or bronchospasm. The dose that you start will vary depending on what issue they've got. But dexamethasone is a useful one to have in mind. You can also use it for intractable hiccups in palliative care. Now, other issues. So people can experience intestinal colic and in that case, hyoscine butyl bromide can be quite effective. You can initially start them on 20 mg subcut and then put um maintain dose of 60 to 100 mg over 24 hours hours via a syringe driver bone pain. Um So you start with the your normal pain ladder and then if applicable, it would be useful to discuss it with an oncologist regarding whether a will radiotherapy be effective or B bisphosphonates, uh bisphosphonates would probably be act in 3 to 4 weeks, radiotherapy a bit longer, about six weeks and you see an effect. Uh but with uh uh the patient might benefit from either of these, the other issue they can have is muscle spasms, which is a bit of a tricky one. You can try simple measures like heat, massaging it. Uh transcutaneous electiveness, electric stimulation is an option. And if they're widespread and there's multiple trigger points, then you can consider benzodiazepines such as diazePAM or Baclofen. OK. Uh Now we've got one of the team members who a case. Yeah, Devon, I'm just gonna present my own slide just because I've made a couple of changes. So if you don't mind just uns sharing and then I will share mine. Um I'm Rachel. I'm just gonna be taking over to do um a quick case with you. OK. Um And Deca, can you see that? All right. Yeah, I can see it all. Perfect. Ok. So um so this is kind of just to summarize everything that we've done uh that Devika has talked about. Um So you've got John, he's 65. He's got metastatic pancreatic cancer and he's presenting with severe persistent abdominal pain relating to his cancer. Um and it's, he rates about an eight out of 10 in severity. Uh He's currently taking Oramorph 10 mgs and he's taking that uh about every four hours P RN. Um, but his pain is still poorly controlled on this. Um, his recent blood show, he's got um, a slightly de a slight deterioration in his kidney function. Um, and he doesn't wish to have a patch. Do you guys have any other kind of alternatives that you can think of in how you would like to manage his pain? I can't currently see the chart. Um Is there anything in the chat at the moment? You've got long acting opioids syringe driver? Yeah. Ok. So good options. Um So for someone who, um kind of is, is coming as an outpatient, you would think about thinking like oral, oral options or maybe a patch um for someone in hospital or, you know, who is kind of very much towards the last days of life, you might think about a syringe driver. Um So they're, they're definitely good options. So things like, um long acting opioids is something that you might consider. Um Now, in terms of, um, kind of kidney function. So devi mentioned earlier, there are a couple of options in terms of um oxyCODONE. That is a good option for patients who have a slight deterioration in their renal function, but not people who have severe renal impairment. And for more information about kind of deranged user that we have done a separate talk as part of this series on uh de prescribing and pain management with deranged user, which you can refer back to. Um But one option is definitely modified Release oxyCODONE with breakthrough oxyCODONE. So let's work out with the conversions that Devi has talked about. Um So you decide to switch his Oramorph to modified release oxyCODONE with some breakthrough P RN immediate release oxyCODONE. So he's currently taking an average of 60 mgs of Oramorph daily. What dose of modified release oxyCODONE and P RN Immediate release oxyCODONE should he be given instead? And I'll give you a second to work things out and if you guys need a little reminder of the conversion rate, so it's 1 to 1.5. Um So you would divide by 1.5. Someone said 40. Mhm Yeah. Yeah. One response for faulty good. So II will I'll show you my workings out then. So oral morphine to oral oxyCODONE has a conversion rate of 1.5 to 1. Um So you'd be dividing by 1.5. So he's taking 60 mg per day of oral morphine, which is equivalent to 40 mg per day of oral oxyCODONE. Now making that into a sorry someone's just said they can't see my workings out. Let me just, yeah, we can see it now. You can see it now with the answer but now it's gone. Can you see that? I think you stopped sharing. Sorry, sorry, I'll share it again. Is that better? Yeah, I can see it now. Sorry about that guys. So yeah. So oral morphine to oral oxyCODONE is 1.5 to 1. So you'd want to be dividing by 1.5. So if he's having 60 mgs a day of oral morphine, that's equivalent to 40 mgs a day of oral oxyCODONE. Um Now, if we want to make that modified release, we want to be dividing that, that into two equal doses so that he can take it twice a day. Um So it will be 20 mg of modified release oxyCODONE BD. Now, in terms of breakthrough analgesia, um we normally do 1/6 of a dose um of the kind of daily amount um that we give. So our daily amount is 40. So we'd want to be dividing our daily amount by six, which gives this horrible number of 6.66. Um So generally we'd rather kind of round down. So between 1/6 and 1/10 if, if possible, um you can say 6 mg, that's absolutely fine. Um But 5 mg is probably easier for them to measure. So roughly 5 to 6 mg um of um of immediate release for um your breakthrough analgesia. Are there any questions about that? Good? So I will hand over back to Devika. Yep. I think those are the resources that I've used. So they've got B NF have got good prescribing in palliative care and health improvement, Scotland as well have quite good guidelines. Um And those are the main, main ones that I would direct you guys to any questions. Yeah. Can't say any. Thank you so much, Devia. Oh, it's all right. Thank you. Um, and also uh just to make everyone aware. So, um this is part of a pain Management teaching series. Um We've got a few talks we've already done. Um, so uh pain management kind of an overview. We've got pain management inter us, we deranged LFT S and then upcoming talks. Um, we've got pain management uh with chronic pain and in the trauma patient. Um, so follow, follow us for kind of more, more talks on this topic. And if you want to refer back to the talks that have already done, then they're all er saved and have been recorded and this one has been recorded as well for you to refer back to. Cool. I think someone's asked if they can get the slides uh severe and someone else a question about severe renal function. Uh Usually we refer to as anyone with KD five. No. So in terms of in terms of managing with severely deranged renal function. So we have one of our previous talks is all on managing pain with patients with deranged user and renal impairment. So we've got kind of a whole half an hour talk on that if you want to refer back to that. All right, that's great. Thank you everyone for attending. Thank you so much. Oh, that's all right. Bye everyone. Thank you for coming. Thanks for joining in and do uh fill up the feedback form and then we will send the slides after that. And thanks Deca, thanks Rachel for, for presenting as well. Thank you. Bye bye.