Palliative Pain Management

Clinical assessment

Thorough pain assessment is key: Duration, Severity (0-5 scale), Site/Radiation, Nature (stabbing, throbbing etc.), Periodicity (constant/intermittent), Relieving/Aggravating factors, Accompanying symptoms. Assess for multiple pain types/sites. Targeted physical examination. Differentiate between Nociceptive (intact pathways, responds well to ladder) and Neuropathic pain (nerve damage, partial response to ladder, needs adjuvants).

Investigations

• Investigations primarily target the underlying cause of pain (e.g., X-ray for bone mets/fracture, imaging for nerve compression).
• No specific lab test for pain itself.

Diagnostic criteria

Based on patient report and clinical assessment characterizing the pain type (nociceptive vs. neuropathic) and severity to guide management according to the WHO analgesic ladder.

Non-pharmacological management

• Lifestyle adjustment.
• Patient counselling and explanation.
• Massage with aromatherapy oils (may help neuropathic/muscular pain).
• Reflexology.
• Application of heat or cold packs.
• Relaxation techniques.
• Distraction therapy.
• Treat underlying cause where possible (e.g., surgery, radiotherapy for cancer).
• Social and spiritual support.
• Rest (e.g., for acute back pain on a firm surface).

Pharmacological treatment

• WHO Analgesic Ladder Approach:
• Step 1: Mild Pain (Non-opioid +/- Adjuvant)
• - Paracetamol: 1g Q6H (Adult); 10-15mg/kg Q6H (Child). (Use 500mg in elderly). Caution liver toxicity with prolonged high doses.
• - +/- NSAID: Ibuprofen 400mg Q6-8H (Adult); 5-10mg/kg Q6-8H (Child >3mo). OR Diclofenac 50mg Q8H (Adult).
• - NSAIDs preferred for bone pain. Caution >10 days, renal impairment, GI risk.
• Step 2: Moderate Pain (Weak Opioid/Low-Dose Morphine +/- Non-opioid +/- Adjuvant)
• - Continue Step 1 analgesics.
• - Low-Dose Morphine (Recommended 1st line if available): 2.5-5mg PO Q4H (Adult); Child doses see UCG table (start 0.01-0.2mg/kg based on age).
• - OR Codeine 30-60mg Q6H (Adult max 240mg/day). Not used in children.
• - OR Tramadol 50-100mg Q6H (Adult max 400mg/day). Not used in children.
• - Add laxative (e.g., Bisacodyl 10-15mg nocte +/- Liquid Paraffin 10ml OD) unless diarrhoea present.
• Step 3: Severe Pain (Strong Opioid +/- Non-opioid +/- Adjuvant)
• - Continue Step 1 analgesics. STOP Step 2 weak opioids.
• - Morphine: Start 7.5-10mg PO Q4H (Adult); Child doses see UCG table (adjust based on age). Double dose at night.
• - Titrate dose up by 30-50% as needed for pain control.
• - Breakthrough dose: Give equivalent additional dose as needed (e.g., before painful procedures). If used regularly, increase regular dose.
• - Dose adjustment needed for elderly, renal impairment.
• - Continue regular laxatives.
• Adjuvants (Add at any step as appropriate):
• - Neuropathic Pain:
• - Amitriptyline 12.5-25mg nocte (Adult, max 50-75mg); 0.2-0.5mg/kg nocte (Child 2-12yrs, max 25mg). Avoid in heart disease.
• - Carbamazepine (Stabbing pain/2nd line): Start 100mg BID (Adult); 5-20mg/kg/day divided (Child). Increase gradually.
• - Clonazepam 0.5-1mg nocte (Adult, 2nd line).
• - Phenytoin (for stabbing pain like trigeminal neuralgia - mentioned in 13.1.3 text)
• - Bone Pain/Swelling/Nerve Compression:
• - Dexamethasone 4-8mg OD (Adult).
• - Prednisolone 1-2mg/kg/day (Child).
• - Smooth Muscle Spasm:
• - Hyoscine Butylbromide 20mg Q6H (Adult); Child doses see UCG table.
• - Skeletal Muscle Spasm:
• - Diazepam 5-20mg nocte (Adult); Child doses see UCG table.
• General Opioid Principles:
• - Give by the clock, by mouth, by the patient.
• - Liquid morphine available and well-absorbed.
• - Manage side effects proactively (see below).
• - Cautions: Respiratory depression (rare with oral titration), head injury, severe liver/renal disease (adjust dose), elderly (adjust dose), concurrent CNS depressants.
• - Avoid Pethidine for chronic pain.
• Opioid Side Effect Management:
• - Constipation: Bisacodyl +/- Liquid Paraffin (Prophylactic).
• - Nausea/Vomiting (Usually transient): Metoclopramide 10mg Q8H PRN for 3-5 days (adjust dose for children).
• - Drowsiness/Confusion: Titrate opioid dose down slowly if excessive and persistent.
• - Respiratory Depression (Mainly parenteral use): Naloxone 0.4-2mg slow IV PRN (Adult); 0.01mg/kg slow IV (Child).

Monitoring

Regular pain assessment (score, relief). Monitor for and manage opioid side effects (constipation, nausea, drowsiness). Monitor effectiveness of adjuvants. Adjust doses based on response and side effects.