Download Total pain – physical, psychological and spiritual TOTAL PAIN

Goodfellow Symposium 2007
Total pain – physical, psychological and spiritual
Professor Rod MacLeod
THE CONCEPT OF TOTAL PAIN
The concept of total pain has been well established since Cicely Saunders began
talking about pain in the 1960’s. One of the difficulties, however, is that most health
professionals are trained predominantly to deal with the physical aspects and
perhaps more recently, psychological aspects of pain. It is often difficult to identify
spiritual and social let alone other dimensions of pain from the way that we are
trained. The importance of the multi-disciplinary approach is emphasized by the
inability of one person to identify all these aspects of an individual.
It is important also to remember that any symptom may have a number of different
dimensions to it – ‘total’ breathlessness and ‘total’ nausea, are well established.
Who hasn’t been breathless with excitement or anticipation; who hasn’t been sick
with fear or worry?
One of the difficulties that we face in palliative care is that the focus may be often
on the pain rather than the person. We are well accustomed to dealing with
nociceptive and neuropathic mechanisms and psychological processes. Physical
components, social isolation, family distress, and spiritual loss, can all be addressed
by the multi-disciplinary team. These components often lead to a perception of pain,
but isn’t the real problem our attempt to alleviate suffering? Suffering is something
which we can all identify. Suffering is something which is unique to each of us. I
would contest that all suffering can be relieved. I believe it to be part of the human
condition. We can certainly alleviate some aspects of suffering, but as will be seen
later, there are some things that cannot be fixed.
PHYSICAL
PSYCHOLOGICAL
TOTAL PAIN
SOCIAL
SPIRITUAL
PHYSICAL PAIN NOT DIRECTLY RELATED TO CANCER
We are all comfortable, I think, with the physical aspects of pain. Much of palliative
care is concerned with cancer and cancer pathology and we are well used to dealing
with that. Just because you have cancer, it doesn’t mean to say that you are
protected from non-cancer pathology. Bunions, haemorrhoids, indigestion, tension
headaches – all will produce pain and if not addressed, will go untreated.
Much of the therapy that we offer people is painful. It is perhaps easy to forget how
painful surgery may be or radiotherapy, even chemotherapy can produce pain. The
debility that goes with long term ill-health can allow us to feel the pain more acutely.
NEUROPATHIC
MECHANISMS
PSYCHOLOGICAL
PROCESSES
PAIN
NOCICEPTION
PHYSICAL
COMPONENTS
SOCIAL ISOLATION
FAMILY DISTRESS
SPIRITUAL LOSS
SUFFERING
ANGER
One of the aspects of palliative care which is difficult to adjust to is the concept of
anger producing pain. Much has been made of the “chronic niceness” of hospice
staff. It is perhaps difficult to express anger with those who are caring for you but
bureaucratic bungling, delays in diagnosis and treatment and the unavailability of
doctors are all just causes for anger. The ultimate failure, therapeutic failure, is
enough to create anger within us all. Modern medicine creates the belief that we
can cure most things. The reality is that there are still many things that are
unresolved and at the end of life, people are often angry about the process that they
have been through in an attempt to cure their disease. Allowing this anger to be
expressed can alleviate some of the distress that anger causes.
ANXIETY AND FEAR
We all have anxieties and fears; we all worry about our family, about finances and
about the future. Many of us will worry about the process of dying, the potential
loss of control and the increase in suffering or even the blackness of death. Talking
to spiritual counselors and other carers can often alleviate these problems, but a fear
that is more difficult to alleviate is the fear of losing dignity. As the body weakens, it
is often hard to understand how one can remain in control. Many of the things
which are “done” to people who are dying, by necessity, are undignified. Many of us
fear our own inappropriate speech, delirium or incontinence.
SADNESS
One of the most difficult concepts to get across to many is that death is almost
always sad. Sadness is something that cannot be alleviated by medication. Sadness
results from various losses; loss of independence, loss of our future, and loss and
change in our roles within society. We may remain a father, a brother, a son, a
friend, but when sick, those roles will necessarily change. The helplessness which
goes with chronic illness and weakness is frightening. The disfigurement that brings
sadness is not the gross changes of an amputation or a mastectomy but the subtle
changes in skin texture or colour, the loss of weight, the greying or thinning hair.
SPIRITUAL UNREST/DISTRESS
Finally, in this picture comes the problem of spiritual unrest. Spiritual care in any
setting is not easy to define and is often subjective, arbitrary and personal. It is
generally assumed to include an individual’s beliefs, values, sense of meaning and
purpose, identity, and for some people religion. It may also encompass the
emotional benefits of informal support from relatives, friends, religious groups and
more formal pastoral care. For many, existential questions about the human
condition can be ignored during many phases of life but are brought into acuity at
the end of life. Because of the intensely personal nature of spirituality it may be
tricky to identify specific issues for individuals but the concepts of hopelessness and
lack of understanding are perhaps easier to identify with. We all have secrets; we all
have an element of guilt within our lives that may come to haunt us at the end of
our life. Allowing these fears to be expressed and some of that hopelessness and
helplessness to be verbalised, can relieve some of the spiritual distress that
contributes to pain. This then is one further aspect, one other dimension of the
totality of pain.
DEBILITY
HELPLESSNESS
THERAPY SIDE
EFFECTS
NON CANCER
PATHOLOGY
LOSS
GUILT
of independence
of future
of roles
LACK OF
UNDERSTANDING
CHRONIC FATIGUE
AND INSOMNIA
CANCER
SPIRITUAL
UNREST
HELPLESSNESS
DISFIGUREMENT
PHYSICAL
SADNESS
TOTAL PAIN
ANGER
BUREAUCRATIC BUNGLING
DELAYS
in diagnosis
in therapy
UNAVAILABLE DOCTORS
THERAPEUTIC FAILURE
ANXIETY
FEAR
of dying
of pain or suffering
of death
WORRY
about family
about finances
about future
LOSS OF DIGNITY
ASSESSING PAIN
Pain is not a universal symptom. Three-quarters of patients with advancing cancer
will experience pain which of course means that one-quarter will not. Of those that
have pain, one-fifth will have only one pain. One third will have four or more pains;
this is important to remember when making the assessment.
So what to do with the pain that you have identified?
TREATING PHYSICAL PAIN
The WHO analgesic ladder is now well established as the most effective means of
treating cancer pain. It is self-explanatory. The rules of the ladder are that
wherever possible, medication should be given by the mouth, by the clock, for the
individual. When one reaches the maximum dose of the first step, move on to step
two. There is a tendency to miss out this step and move straight to strong opioids.
This should be avoided. The advent of the ingestion of opioids is a frightening
phenomenon for most people. Most people’s perception of morphine is that it
indicates the end. The introduction of opioids by the use of codeine or
dihydrocodeine or the addition of tramadol is often a useful way to help people grow
accustomed to this change in their life. Slow release preparations are available and
can be titrated to an individual’s pain. However, once the maximum dose of the
weak opioids is reached morphine should be started without delay. Once again it is
important to give the drug by the mouth, by the clock, if possible. Morphine is a
four-hourly drug and should be titrated using four-hourly preparations. Once a
stable dose is reached, then a long-acting preparation such as M-Eslon can be
utilised. M-Eslon is a 12-hourly drug.
PRINCIPLES OF ANALGESIC USE
The Analgesic Ladder
STEP THREE
STEP TWO
STEP ONE
STRONG OPIOIDS
morphine
oxycodone
fentanyl
methadone
WEAK OPIOIDS & NSAID
codeine
dihydrocodeine
tramadol
SIMPLE ANALGESICS & NSAID
paracetamol
ibuprofen
aspirin
ALWAYS REMEMBER
Co-analgesics
Specific therapies
(radiotherapy, surgery,chemotherapy,hormone)
If the dose of morphine is not sufficient, the correct way to proceed is to increase
the dose of long-acting not to reduce the time interval between doses. Only a tiny
proportion of patients require long-acting opioids at a shorter time interval than 12
hours. For all intents and purposes, long-acting opioids should be given twice a day.
The dose should be increased until the opioid sensitive pain is alleviated.
The potential now to utilize differing opioids in New Zealand has increased.
Oxycodone is relatively new to New Zealand and is a real alternative to morphine. It
seems to have more effectiveness for neuropathic pain and so is particularly useful if
there is a mixed pain picture. It has great oral bioavailability than morphine so
should be given in lower milligram doses (about half). It is formulated in normal
release (oxynorm) and continuous release (oxycontin) preparations. Liquid and
parenteral preparations are available but currently have a part charge.
Fentanyl is another real alternative – particularly useful as it is a transcutaneous
preparation and therefore useful when the oral route is compromised. It is available
in fixed doses that are particularly useful when pain is stable –currently no
immediate release preparation of fentanyl is available in New Zealand. Methadone is
a difficult drug to use in the community and specialist advice should be sought about
introducing it. It is another opioid that is valuable in the management of mixed pain,
where there is thought to be a neuropathic element.
Always remember to consider the use of co-analgesics such as non-steroidals,
steroids, anti-convulsants, anti-depressants and possibly anti-arrhythmics, for the
relief of opioid semi-responsive pain such as neuropathic pain. Remember too, to
employ specific therapies (radiotherapy, surgery, chemotherapy or hormone
therapy) to aid in the quest for analgesia.
The following list indicates the commonest pains of a group of patients admitted to
an inpatient hospice. It can be seen that not all of these are directly related to the
malignant process itself.
Commonest pains
Bone
Visceral
Neuropathic
Soft tissue
Immobility
Constipation
Myofascial
Cramp
Oesophagitis
Degeneration of the
spine
There are obviously other factors which affect the pain threshold. It is easy to
identify things other than pharmacological agents which can change the perception
of pain.
FACTORS AFFECTING PAIN THRESHOLD
Threshold Lowered
Discomfort
Insomnia
Fatigue
Anxiety
Fear
Anger
Sadness
Depression
Boredom
Mental isolation
Social abandonment
FACTORS AFFECTING PAIN THRESHOLD
Threshold Raised
Relief of other symptoms
Sleep
Sympathy
Understanding
Companionship
Creative activity
Relaxation
Reduction in anxiety
Elevation of mood
Analgesics
It is important to employ all of these factors in an attempt to change the pain
threshold – analgesics are just one part of a total approach to pain management.
Failure with opioids is often related to one of the following:
1. Opioids are often under prescribed because of fears that:
• tolerance will rapidly develop
• addiction will be a problem
• there will be depression of respiration
• the patient may use the drug for suicide
• the relatives may use the drug for euthanasia
• the opioid will be stolen by or sold to an addict
2. Neurolytic procedures are not employed
3. Inadequate attention is paid to insomnia.
4. Impaired absorption of the drug due to gastric pathology, etc.
5. Renal function has not been assessed.
With meticulous attention to detail, it is possible to reduce pain in almost all cases.
Over 90% of cancer pain can be alleviated. Meticulous attention to detail is the
hallmark of good palliative care and with that detail employed by a multi-disciplinary
team, pain as a major symptom should be alleviated for the vast majority of people
with advancing disease.
R D MacLeod/Auckland/4.04