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Australian Advanced Prostate Cancer Forum Pain Management 22 March 2019

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DavidAbrahams

The bulk of this presentation is taken from Palliative Care Australia website and they are accordingly acknowledged and thanked. David H Abrahams 22/03/19 

 

What is pain? 

Pain is unpleasant sensation, suffering or distress of the body or mind. Pain hurts and it wears you down. lt can make it hard for you to be active and make you feel tired and tense. Pain often accompanies cancer and other progressive diseases and it can affect all aspects of your life- psychological, emotional and spiritual. 

Why are we afraid of pain? 

Not all people living with terminal illness experience pain. However, many people living with a terminal illness are afraid of pain because they worry that pain cannot be controlled without awful side effects. Fear of pain adds to the total impact of pain. It is important to speak up about your pain and your fears about pain. Be honest and ask questions so that you can be given accurate information. 

Can pain always be controlled? 

Most pain can be relieved or controlled. Bringing pain under control and keeping it there means assessing each aspect of pain and monitoring it. These are core skills of palliative care doctors and nurses. 

How can I help control my pain? 

Good pain control requires good communication amongst patients, carers, medical and nursing staff. It is important to be open and share information so your care team knows exactly what is happening with your pain. Sometimes people report less pain than they experience because: 

They value stoicism- they don’t want to appear weak 

People interpret their pain according to their particular life experiences, values and beliefs. If you value stoicism for religious or cultural reasons, you may wish to discuss the matter with your religious leader or a pastoral carer. None of the major religions urges its followers to reject pain-killers {analgesics) in terminal illness. If you think that it is weak to ‘give in’ to pain, you might consider whether analgesia will free your energy for more important things. 

They think increasing pain might be a sign of a worsening condition 

Sharing your fears about your condition with the palliative care team can lessen your concern. Even if your situation is not good, discussing it may reduce your anxiety. 

They think they will not have a say about their pain control 

Control of your pain is negotiated between you and your doctor and nurses. Pain control plans are tailored to meet your particular needs and are adjusted as your needs change. You have the say as to whether you want more or less pain relief. 

They are afraid that if they have strong pain-killers now, there will be nothing strong enough for them later 

There is no set limit to the amount of pain relief offered. You cannot ‘run out’ and it can always be increased or decreased according to your experience. 

How is pain controlled? 

Medications are the foundation of pain control. There are two main groups of pain medicines ranging from mild pain relievers such as aspirin and paracetamol though to medium and strong relievers, such as morphine and related drugs (opiates). Anti-inflammatory, anti-depressant and steroid medication may also have a complementary role for some patients and some sources of pain. The right mix of medications is part of the expertise of the palliative care team. 

Must I take medication? 

Medication is the core treatment of pain in terminal illness. Surgery, radiation and ‘nerve block’ (like a local anaesthetic) are used to control pain in some cases. 

When regular (eg: 4, 12 or 24 hourly) pain medication has been prescribed for you, you must take it on time. Do not wait to experience pain. The schedule is designed to prevent pain from occurring, not to treat it after it arrives since this type of pain tends to be with you continuously. 

Other measures include: 

Hot packs 

·                                 Careful positioning and repositioning appropriate exercise or support for a painful body part 

·                                 Special physiotherapy techniques, such as laser therapy and ultrasound 

·                                 Therapies such as massage, relaxation meditation, hypnosis, music therapy, aromatherapy, acupuncture and acupressure 

·                                 Distraction – any activity that diverts and holds your attention will lessen your awareness of pain 

·                                 TPCSG guest speaker for March was a “Niagra” Consultant who supply massage equipment as well as Niagara Therapy. The talk was on the importance of exercise and hydration! 

Complementary measures are used as well as medical treatments. They increase the effectiveness of drug therapy and may reduce the amount of medication required. 

If I take strong pain-killers (opiates), will I become addicted? 

People sometimes think that opiates must be addictive because they come from the same source as heroin (opium). Heroin, injected into a vein, gives a rush of pleasure, called euphoria, which can be highly seductive. People who inject themselves in this way for no medical reason can become addicted and will need increasing quantities of the drug to remain euphoric or to avoid withdrawal symptoms. 

Medically prescribed opiates are used in a very different way. The dose neutralises the pain. It does not give a ‘rush’. The chemical effect is taken up by the pain so that any feeling of euphoria is very mild or not noticed. Medication is given in the easiest way, usually by mouth (as a liquid, tablet or capsule); by injections (into skin, muscle or vein) or on the skin (in a patch quite like a nicotine patch). 

Some patients will remain on the same dose even though their disease is progressing. Others need increasing doses of pain relieving medication. This is not evidence of addiction. The correct dose is the one that stops your pain and makes you comfortable. People vary, pains vary and there is no one right dose for everyone. 

What are the side-effects of opiates? 

Morphine and similar drugs cause ongoing constipation, which can be controlled with laxatives. Some people experience nausea, sleepiness or confusion when they first take these medications, for some people this can last up to five days. These symptoms usually clear up when the person adjusts to the medication; you can always discuss these symptoms with the doctors and nurses helping you with your care. 

A few people experience continuing, unacceptable side-effects. In such cases other drugs are used or low doses of two or more drugs are combined to relieve pain without the side-effects. Palliative care physicians are specialists in pain control. If your pain control is less than perfect, seek specialist advice. 

Does morphine suppress breathing? 

An overdose of morphine in someone not accustomed to taking it, may suppress breathing but in most cases if the morphine has been properly prescribed this will not occur. Indeed, morphine can be used in low doses to ease difficult breathing and to suppress chronic cough. 

What about breakthrough pain? 

There may be times, even if you receive regular or continuous pain relief, when you will experience pain. This is called breakthrough pain and is very distressing for you and your carer. Your doctor will probably have prescribed extra medication to be taken as required. In this case take the extra medication, make a record of it, and make sure you tell the nurse or doctor. If extra medication for breakthrough pain has not been prescribed, get help from your palliative care team or General Practitioner without delay. Sometimes breakthrough pain means you need extra (or different) medication before some planned event requiring extra exertion or effort, such as showering. Often it means that your regular medication needs to be increased so that you remain comfortable. The goal of pain management is to prevent pain; it is more difficult to try to control pain once it has recurred, than to routinely treat it before you experience it. 

Pain is a symptom most feared by people living with a terminal illness, but often it is not a source of worry for those receiving palliative care. Modern pain management means that patients can expect to remain virtually pain free throughout their illness. 

Fentanyl (Ack: Alcohol & Drug Foundation) 

What is fentanyl? 

Fentanyl is part of a group of drugs known as opioids. Opioids interact with opioid receptors in the brain and elicit a range of responses within the body; from feelings of pain relief, to relaxation, pleasure and contentment. 

It is prescribed in the event of chronic, severe pain as a result of cancer, nerve damage, back injury, major trauma and surgery 1 In Australia, fentanyl is a schedule 8 drug.2 It is about 80 to 100 times stronger than morphine.3 

What it looks like  

Fentanyl is available in many forms. Pharmaceutical fentanyl is used for managing acute or chronic pain. Illicit fentanyl can be manufactured for use in the illegal drug market. 

Medicinal use  

Medicinal fentanyl comes in a number of different forms and strengths including: 

·                                 Transdermal patches (Durogesic® and generic versions) 

·                                 Lozenges/lollipops (Actiq®) 

·                                 Intravenous injection (Sublimaze®) 

With respect to Fentanyl I have been using the patches for 5yrs after 6yrs of swallowing other opiates with an ever increasing dosage all to no avail. The Palliative Care Consultant had the pain controlled within 3 months. Presently on 100mcg/hr with a very occasional break through pill (Oxy-Norm 20mg)(DHA) 

 

VERY IMPORTANT 

You the patient travelling the Advanced Prostate Cancer Journey should not suffer from debilitating pain that can reduce your quality of life, let alone die in acute pain and distress! 

Your medical oncologist job is to keep you alive and hopefully pain free to some degree! 

Your Palliative Care Consultant helps you to control and mange pain thus ensuring you have quality of life during your journey and at the end you die with dignity, NOT DOUBLED OVER IN PAIN! 

Some Oncologists are not happy that their patient goes to a Pain Management specialist to have their pain controlled, because it may mask other symptoms of illness.  

·         If you the patient suffer from chronic pain caused by the cancer get help!  

·         Do not be a woos obtain a referral from your GP to visit a Palliative Care Consultant.  

·         Visiting a PCC does not mean you are about die! Think also about your family and friend.  

·         They do not like to see you suffering! (DHA) 

YOU the Patient 

Palliative care provides high quality health care to people living with a life-limiting illness to live as well as they can by managing pain and symptoms to ensure their quality of life is maintained. 

Why do I need it? 

Palliative care will help you manage your illness, particularly pain and symptoms so you can continue to live life as well as you can while dealing with your illness. You may need it or want to have it from diagnosis or you may choose to take it up once your illness progresses to a certain stage. You may have an on-off rotation through palliative care through various stages of your illness as you have periods of wellness and illness. 

How do I get it? 

Palliative care can be accessed through referral from your General Practitioner, medical specialist or other health provider 

To find a service in your local area go to the National Service Directory. 

Palliative care is available to anyone with a life-limiting illness, not just cancer patients. People living with dementia, chronic conditions or degenerative conditions can access palliative care. 

How much does it cost? 

Most palliative care services are free, but there may be some costs associated with hospice and hospital care. 

Who does it? 

Palliative care is multidisciplinary team care – so care is shared between a range of providers from specialists to General Practitioners, nurses, allied health professionals and social workers. 

Who will help my family when I am gone? 

Palliative care also supports carers and family members. There are a number of support services for people who are grieving. There is information in the ‘I’m a carer’ section about grief and support services. 

 

Help, Advice and Resources: 

For more information about palliative care and what it means to you, click on the links below. These pages are also available to download. 

·                                 What is palliative care? 

·                                 Advance care planning 

·                                 Asking questions can help 

·                                 Diabetes and palliative care – information for patients 

·                                 Directory of Services 

·                                 Dying to Talk Discussion Starter 

·                                 Facts about morphine and other opioid medicines in palliative care 

·                                 Learn more about pain and pain management 

·                                 The dying process 

·                                 Understanding grief 

·                                 Your choices and decisions 

·                                 Palliative Care in Aged Care 

 

Palliative Care Australia 

Street address 

Unit 8 
113 Canberra Avenue 
Griffith ACT 2603 

Mailing address 

PO Box 124 
Fyshwick ACT 2609 

t: +61 2 6232 0700 
e: pca@palliativecare.org.au 
w: www.palliativecare.org.au 
 

ABN: 85 363 187 904  

Office Hours 

Monday – Friday, 8.30am – 4.30pm  AET 

Member Organisation Contact Details 

NSW 

Palliative Care NSW 

PO Box 487 
Strawberry Hills NSW 2012 

t: 61 2 9206 2094 / 0403 699 491 
f: 61 02 9281 0157 
w: www.palliativecarensw.org.au  
e: info@palliativecarensw.org.au 
 

SA 

Palliative Care South Australia 

PO Box 435 
Fullarton SA 5063 

t: 61 8 8271 1643 
f: 61 8 8271 7494 
w: www.pallcare.asn.au  
e: pallcare@pallcare.asn.au 
 

QLD 

Palliative Care Queensland 

PO Box 418 
THE GAP QLD 4059 

t: 07 3511 1539 
w: www.palliativecareqld.org.au 
e: hello@palliativecareqld.org.au
 

VIC 

Palliative Care Victoria 

Suite 3C, Level 2, 
182 Victoria Parade 
East Melbourne VIC 3002 

t: 61 3 9662 9644 
f: 61 3 9662 9722 
w: www.pallcarevic.asn.au 
e: info@pallcarevic.asn.au
 

WA 

Palliative Care WA 

15 Bedbrook Place 
Shenton Park WA 6008 

t: 1300 551 704 
f: 1300 551 704 
w: www.palliativecarewa.asn.au 
e: pcwainc@palliativecarewa.asn.au
 

TAS 

Palliative Care Tasmania 

PO Box 3060 
West Hobart Tas 7000 

t: 61 3 6231 2799 
f: 61 3 6239 6030 
w: www.tas.palliativecare.org.au 
e: admin@tahpc.org.au
 

ACT 

Palliative Care ACT 

PO Box 31 
Campbell  ACT  2612 

t: 61 2 6255 5771 
f: 61 2 6273 9590 
w: www.pallcareact.org.au 
e: office@pallcareact.org.au
 

NT 

Palliative Care Northern Territory 

PO Box 4489 
Alice Springs NT 0871 

t: 61 8 8951 6762 
f: 61 8 8951 6774 
w: www.pallcarent.org.au 
e: sclyne@hotmail.com 
 

Affiliate Members 

Australian and New Zealand Society of Palliative Medicine 

PO Box 7001 
Watson ACT 2602 

t: 0458 203 229 
f: 61 3 8677 7619 
w: www.anzspm.org.au 
e: executive@anzspm.org.au
 

Palliative Care Nurses Australia  

Palliative Care Nurses Australia Inc. 
PO Box 210, Port Pirie, SA, 5540. 

t: (02) 8405 7921 
w: www.pcna.org.au  
e: admin@pcna.org.au
 

 

Ack: Palliative Care Australia 

David H Abrahams, North Toowoomba, Qld. 4350 Australia, March 2019 

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Patrick Turner
On 3/25/2019 at 12:27 PM, DavidAbrahams said:

Palliative care will help you manage your illness, particularly pain and symptoms so you can continue to live life as well as you can while dealing with your illness.

Hi David, Thanks for posting on pain relief methods, and about the low likelihood of addiction to Fentanyl. I have not yet reached the stage of seeking palliative care, but I would not hesitate if I had to. There is nothing weak about putting up with pain, its strong to admit you have pain and seek to ease it.

Near my right hip joint, there are pea sized Pca mets in pelvis and top part of femur. These are irritating the joint, and there was pain when I cycled anywhere, so I had MRI and I have some arthritis, sure, but the Pca and arthritis are making the joint painy, so I left the bike alone, and concentrated on house fix-ups before the time came when I could never do anything much. All that went well, and I also just had 20 Grey of EBRT to the right hip and mets, and doc and nurses say pain should ease in 2 weeks, all without painkiller drugs.

I have my 4th Lu177 shot in about 3 weeks. Doc put me onto Enzalutamide which doc said should work on repressing the Pca, because chemo last year plus Lu177 so far would have made my Pca express more PsMa avid, so that the 4th Lu177 will be more effective. I hope the doc is right, and I can't know that until a month or two more. The EBRT to hip were just beams up and down through the Pca affected area. I had 70Gy of EBRT as primary treatment in 2010 with ADT, and then it seemed the RT didn't do much, but I accepted the offer this time again, and maybe it works. In 2010, the hip joints were in the horizontal pathway for EBRT, so they have had been radiated before, and maybe that's enough to affect cartilage material and make it fail earlier that it would have otherwise. It is difficult to ever be sure about exact outcomes and side effects. but at least I can type to you all without pain, and do many things, mow lawns, clip hedges, and all manner of house maintenance and some work in shed on electronics, so I have no cause to feel dismal. 

Doc here mentioned a new hip joint. But they need to get the Pca under control. I sure am not able to say I am there yet.

Another man said there are ppl wanting to bring Lu177 treatment to Canberra but they don't have costs covered yet by PBS. Can someone tell Scomo he might score more grey votes if he authorized PBS for Lu177? 

The best time of year is upon us with mild temperatures, splendid autumn weather, no?

Patrick Turner. 

 

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PeterA

Many thanks David.

reference was made to ‘a break through pill’

this implies that it is fast acting in providing relief?

less than 20mins?

PeterA

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