CONTEMPORARY PRINCIPLES OF PAIN MANAGEMENT. Bruce CLEMINSON, Macmillan Palliative Care Education Facilitator, Fellow of the Royal College of General Practitioners & Member, European Association for Palliative Care, Shetland, United Kingdom - - - СОВРЕМЕННЫЕ ПРИНЦИПЫ ОБЕЗБОЛИВАНИЯ. Брюс КЛЕМИНСОН, Координатор образовательных программ по паллиативной помощи центра Мак Миллан, член Королевской коллегии врачей общей практики, Шетландские острова, Великобритания

1. Contemporary principles
of pain management
Moscow – February 4th 2013
Dr Bruce Cleminson MB FRCGP
Macmillan Palliative Care education facilitator

2. Pain is a universal experience in human life
It may be caused
by many different situations & illnesses
70% of people with terminal illness from any cause
will experience pain

3. 1 out of 4 people
at the time of their cancer diagnosis
have pain

4. 3 out of 4 people
with far advanced cancer
have pain

5. In Europe –
at least 3 out of 4 people
die of some kind of terminal illness

6. about 70% of people
dying of any kind of terminal illness
have pain

7. So, more then half of us here … and our patients …
will have significant pain during our lifetime

8. Careful assessment is essential
Most terminal patients have 3 or more pains at any time
– each needing assessment.
use an assessment tool - The Brief Pain Inventory
This approach helps us understand the mechanism of
the pain,
and helps us know which medicine or approach to use.

9. For people with pain
There are WHO guidelines,
written by international specialists
for the treatment of pain.

10. For moderate to severe pain
Morphine is usually needed
For non physical pain a different approach is needed
Whatever the illness, the stage, or the cause of the pain,
patients with moderate to severe physical pain,
should receive Morphine, if needed.
An example

11. The WHO 3 step analgesic ladder (1986/1996)
step 3 - strong opioid
(+/- adjuvants)
eg morphine
step 2 - weak opioid
(+/- adjuvants)
eg Tramadol
step 1 - simple analgesic
eg paracetamol / ibuprofen

12. Tramadol can relieve mild to moderate pain
but not severe pain
An example;

13. Morphine can relieve moderate to severe pain
Morphine by mouth or injection are equally effective
The correct dose is the dose that relieves the pain
There is no upper limit to the Morphine dosage
50% of terminally ill cancer patients with pain
need 60 mgs or more of oral morphine per day

14. Morphine formulations
Normal release oral morphine
1 – useful for bringing pain under control.
2 - useful for break-through pain
Normal release Morphine
and Morphine by injection
only have an action lasting 4 hours
So they need to be given every 4 hours
for effective Pain relief
Morphine injections are mainly used
when the patient cannot take morphine by mouth

15. Sustained release Morphine
Sustained release Morphine is used for
maintaining already established pain control
Sustained release Morphine (MST)
needs to be given regularly every 12 hours

16. For patients and their families,
oral Morphine is easier and more pleasant
For the staff and carers,
oral Morphine is less demanding on their time

17. Successful Pain Management …
can be achieved
in 80 – 90% of patients
in a cost effective way … provided there is:
The availability of Morphine
and alternative WHO step 3 opioids
for moderate to severe pain
Education for healthcare professionals & the public
Specific healthcare policies
Integration of palliative care and hospice services

18. Doctors and patients fears about Morphine …
1 – Will the Morphine kill the patient?
2 - will the Morphine cause addiction?
3 – will the Morphine cause excessive sedation?
4 – will the Morphine dose escalate rapidly?
An example

19. Morphine is
effective
safe
& cheaper than most of its alternatives

20. In summary
What are the contemporary principles of pain management?
Recognise the extent of the problem
Assessment of the pain
Understanding the mechanism of the pain
Selecting the appropriate treatment option
Reassess the pain to confirm effectiveness
The necessary drugs need to be available
Especially all 3 formulations of Morphine
Palliative radiotherapy needs to be accessible
Medical education is needed to ensure quality care
Public education to have the confidence to receive this care

21. Spaceba