1. Revisiting Pain Pathways in Cancer Pain versus Chronic Pain: Apples versus Oranges

The philosophy of Cuisle Beatha has always been to reflect our daily work experience into ‘Science' and explore the potential to constantly improve on our care of patients - the main aim remains to ‘Live well despite advanced disease'. This year we are ‘revisiting' Pain Pathways in depth. We have world experts, in each area of relevance, giving them the task to empower the audience with ‘the clinical meaning' of their area of research interest, in a straightforward and clinically meaningful way. New drugs .i.e. ‘Tapentadol' (Palexia) is explored to ask the question, is it really a strong opioid? And/or is it's main action on the downward noradrenaline re-uptake pathway; that is so effective that it is minimising our need for high dose opioids in appropriately selected patients? Prof. Anthony Dickenson will give his exciting views on this promising new drug that covers a definite pathway involved in pain. Old drugs, .i.e. Cannabinoids, are explored by our own World, NUIG expert Prof. David Finn, as to the potential cannabinoid action in the body for nausea, seizures but also for ‘pain control'; in complex pain. Pain control in children with malignant/ non-malignant pain is also covered by Dr. Mary Devins. Delirium and opioids is topical at present and Prof. Peter Lawlor is speaking on his views having researched and published in this area. Outcome measurement of pain, covered by Prof. Laserina O' Connor,  is complex and frought with difficulty. Pain is a subjective feeling and therefore has a ‘ceiling effect' .i.e. 10/10 can become 20/10... so how do we effectively measure a ‘moving target'?

 A question that is vital to the management of cancer pain is explored in detail- "Have we misplaced cancer pain by placing it in the definition of ‘chronic pain'?" Without a proper definition we have no foundation on which to build a solid understanding of how to ‘treat' and also manage dynamically a patient's pain. We, in our service, have declared cancer pain as ‘acute' pain for almost two decades now- by simply ‘declaring' this, our aim is, akin to post-operative pain to achieve 100% pain control without compromise to the patient. This gives the patient and family ‘confidence' when we achieve this - then we reduce analgesics/opioids often to stop, as treatments act to reduce the cancer, increase opioids as cancer progresses- but our average opioid dose at end of life is very low as a result of the view that the WHO stepladder of pain control goes down as much as it goes up! The intricate relationship between opioids and sepsis indicates the body's preparation for sepsis by maybe producing it's own endorphin like substance. This hypothesis mirrors Prof. David Finn's studies with animal subjects on production of cannabinoids around ‘fight or flight'. This all matters to the ‘dynamic' management of cancer pain and of vital importance, the patient's  and family's trust. The amazing author and patient, John Walsh, has agreed to speak about his experience of severe acute pain and it's full resolution that reflects the above views.

2. Economics of Quality of Life Care in Dementia - Subject of Quality of Life & Symptoms

Day two covers three separate categories, the first session covers the exciting expansion of palliative medicine into areas .i.e. patients with dementia. Dr. Sharon Beatty will explore her role in a new consultant post with specific remit to this area. It will be exciting to see the results of her early work. Following this Prof. Eamon O'Shea will outline the very important area of the economic costs and potential savings within improving quality of live for this patient group. Ms. Marie Lynch from the IHF will explore their findings from Irish studies. Prof. Shaun O'Keeffe will explore the interesting new capacities laws in Ireland and what the implications of this means for all of us.  

3. Let's Define Quality of Life First then Let's Critique the literature research results to date

Prof. Tony O'Brien will lead with the information of the availability of cannabinoids in Ireland, when we are likely to be able to prescribe and what conditions we can prescribe for. Due to his availability, this talk was too important to miss so we have it in this session rather than day one. The rest of this session explores Subjective Quality of Life (SEQoL) measurement in many populations of patients. The subjective measure, I believe, has a lot of similarities to the new Capacity Bill in Ireland as it captures the ‘Hopes and Expectations of the patient in a very individualised and scientific manner. Ms. Orla Keegan, IHF, will explore interesting  developments in bereavement and the implications for family quality of life. Dr. Eoin Tiernan's novel project on capturing the benefits to St.Vincent's Hospital by having a palliative care presence in A&E should fuel debate. Dr. Anne Doherty, Liasion Psychiatrist, will give her views on Dr. Tiernan's MD thesis using Judgement Analysis (JA) to work out how we diagnose depression in a palliative care population. I believe JA has a role for other similar studies that we plan to progress, on selection of patients with stroke for PEG feeding and to understand how patients choose palliative dialysis.

4. Let's Lead the way for New Research for GI Dysmotility!

This final packed session is very meaningful to us as we have been involved in the care of many patients with Gastrointestinal Dysmotility, both from malignant and non-malignant causes. As always in palliative medicine, we are pushed to the limit of our knowledge base to deal with patients with intractable and terrible symptom burden. By extrapolating our knowledge of the use of somatostatin analogues in bowel obstruction, it became clear that combining this drug with prokinetics, we, in essence, are able to artificially account for missing or dysfunctional valves in the upper GI tract. We have always used much higher doses of Octreotide than in the two main RCT's published. The benefit is clear and we want explore with our local experts the body of work we have been doing in Galway. Dr. Eoin Slattery, Mr. Chris Collins and our team will provide interesting talks for debate. We hope to commence an interventional study in this area in the new year.  Prof. Asbjørn Mohr Drewes will discuss the details of opioid induced-bowel dysfunction and the role of Naloxone combined with our use of opioids.  Ms. Ruth Kilcawley will give an exciting talk about the game of life and nutrition.

I really do hope this program stimulates the interest of professionals to come to our conference and experience the wealth of knowledge offered by so many experts in the beautiful surroundings of NUI Galway!

Professor Dympna Waldron MD FRCPI
Professor of Palliative Medicine
Consultant in Palliative Medicine
Galway & Roscommon University Hospitals.

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