Guideline Pain Management in Palliative Care

Guideline Responsibilities and Authorisation

Department Responsible for Guideline Palliative Care

Document Facilitator Name Lana Ferguson & Peter Kirk

Document Facilitator Title Advanced trainee (reg) & Consultant, palliative care

Document Owner Name Peter Kirk

Document Owner Title Clinical Director

Disclaimer: This document has been developed by Waikato District Health Board specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at their own risk and Waikato District Health Board assumes no responsibility whatsoever.

Guideline Review History

Version Updated by Date Updated Description of Changes

Contents

Mild to moderate pain Severe Pain – opioids and adjuvant analgesics

Opioid medications • Morphine • Oxycodone • Fentanyl • Methadone

Adjuvant medications • Gabapentinoids • Bisphosphonates • Ketamine • Lidocaine

Doc ID: 5895 Version: 01 Issue Date: 02 MAY 2018 Review Date: 02 MAY 2021 Facilitator Title: Registrar Department: Palliative Care IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING Page 1 of 23

Guideline Pain Management in Palliative Care

1. Overview Pain may be a patient’s greatest fear and adequate pain relief is essential for their comfort and dignity.

‘Total Pain’ is a concept which acknowledges that pain is caused and influenced by many issues. Physical pain is only one component – attention must be given to psychological problems, social problems, intellectual, spiritual and cultural issues and other concurrent physical symptoms.

Some general principles to consider: • The characteristics and cause of each pain should be established • There are often multiple pain syndromes, each may require a different management approach • Pain in cancer is most often related to tumour involvement but also can be treatment related (e.g. mucositis, constipation, neuropathies) • It is important to remember non-malignant causes of pain and not attribute all pain to cancer e.g. (arthritis, angina) • Regular dosing of analgesics is usually required along with breakthrough dosing • Adequacy of pain relief and development of side effects should be monitored regularly. • Patients must be reviewed carefully for concurrent problems if analgesic requirements increase. • Oral regimens are the most acceptable and convenient. • A multimodal approach to pain management may be needed • When using opioids, simple analgesics such as paracetamol can be continued, adjuvant analgesics may be needed • Medical use of opioids for pain associated with advanced disease rarely, if ever, leads to abuse or opioid addiction. Opioid tolerance can occur. • There is no maximal dose recommended for strong opioids. Large doses may be needed to manage pain however this should be determined in context of efficacy of drug and adverse effect burden. • Opioids do not shorten survival.

1.1 Purpose To provide guidance in the management of complex pain in palliative care patients.

1.2 Scope All waikato DHB medical staff involved in the clinical care of palliative patients will be aware of and familiar with guidelines.