Transcript Symptom management in hospice and palliative care

Pain Control in Hospice and
Palliative Care
Scott Akin MD
Background
• Many patients die in pain
– 62-90% of children report pain at end of life
– Prevalence of pain 64% in advanced cancer
– Pain common in non-cancer (CHF, cirrhosis,
HIV) patients common as well (40% w/in days
of death)
Effective pain management
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Three step process
(1) Assessment all types of pain (physical,
emotional, spiritual)…if physical, what kind?
(2) Treat each type of pain individually, focusing
on specific etiology of each
(3) Continual reassessment of treatment goals
(pain levels, goals of function, mood, sleep,
social interaction, etc.)
Determining type of Pain
• Nociceptive…tissue damage
– Visceral: Difficult to localize (from stretching,
compression, obstruction, infiltration, ischemia)
• “Spastic, cramping, gnawing, squeezing, pressure”
– Somatic: Localized
• “Aching, stabbing, throbbing, squeezing”
• Neuropathic…nerve damage
• “burning, shooting, tingling, stabbing, scalding,
painful numbness”
WHO Analgesia Ladder for
cancer pain
• Step 1: Acetaminophen, NSAID, or another adjuvant
analgesic. Skip this if in moderate or severe pain!
• Step 2: add lower potency opioid (codeinehydrocodone)
or low dose of stronger opioid (morphine). Use ATC
dosing along with PRN.
• Step 3: add/start higher potency opioid (morphine,
hydromorphone, or fentanyl).
-Don’t need to “climb the ladder.”
-Can use adjuvant meds (antidepressants,
anticonvulsants, anticholenergics) at any step.
Adjuvants to opioids
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Acetaminophen (consider scheduled)
NSAIDS (esp for bone mets, inflammation)
Bisphosphonates (for bony pain)
Steroids (for inflammation/edema)
TCAs/anticonvulsants (tegretol,gabapentin)
for neuropathic pain
• Local measures (capsaicin, lidocaine patch)
Drugs to Avoid on
Hospice/palliative Care Settings
• Meperidine (demerol): low potency orally, toxic
metabolites may precipitate seizures & confusion.
Really, only one indication for it: Rigors
• Mixed agonist-antagonists (pentazocine): no more
potent than codeine, risk of hallucination &
agitation. Inhibits analgesia of morphine
• Propoxyphene (darvocet): no more potent than
acetaminophen, toxic metabolites can precipitate
seizures, confusion, cardio toxic, resp depression
• Don’t give anything IM!
Treating Nociceptive pain:
Opioids
• Opioid myths
– “Opioids commonly cause respiratory depression”…not
if administered and titrated carefully. OK, you should
worry if RR <6, has ALOC, or is hypoxic. Be careful
with narcan…rather than give 0.4mg x 1, much more
humane to dilute into 9ml of NS, and give 1-2ml at a
time, slowly, until patient responds.
– “Opioids cause addiction”…Physical dependence,
yes…but addiction (impaired control over drug use,
compulsive use, continued use despite harm)…almost
never.
More opioid Myths
• “Opioids hasten death”…maybe the other way
around (pain is psychologically and physically
destructive, so unrelieved pain may shorten
survival time).
• “Oral opioids are ineffective”…not true, but they
do take longer to take effect, but oral opioids are
preferable because of:
– Cost, ease in administration, less risk of infection (no
need to have IV in place), less chance of dosing error,
and more predictable pharmacologic steady state.
Even more opioid myths
• “Opioids commonly cause nausea”…false, and if
true for specific patient, we have good meds to
help (or can switch to another opioid).
• “Opioids commonly cause euphoria”…Not in
patients who are in pain. A patient’s mood and
sleep is likely to improve with effective relief of
pain.
• “Patients rapidly become tolerant to opioids”…not
true, but will need higher doses when disease
progresses.
Basic opioid principals
• There is significant variation from one
individual to another in effective dose.
• Take pt’s age, weight, and prior experience
with opioids into account
• Use oral route if able (just as effective)…IV
only if unable to take POs, have decreased
LOC, or uncontrolled pain
Opioid principals
Know pharmacology:
– Short-acting PO meds generally reach their peak after
45-60min, and last 3-5 hours (IV peak is about 5-15min
and duration is 1-2 hours).
– Most short-acting PO meds (morphine, oxycodone)
can be increased safely q 2 hrs (inc by 25-50% for
mild/mod, and 50-100% for mod/severe pain).
– Long acting meds (ms-contin/oxycontin) should be
increased every 24 hours, based on PRN use.
– Should not increase methadone more often than q 4-7d.
More opioid basic principals
• At first, use short acting drug, then based on
24 hour need convert to long acting…with
PRN for breakthrough (which should be
approx 10% of 24 hour dose).
• Example: In “normal” person start q 4 hour
– 5mg of short acting morphine or
– 1mg hydromorphone (dilaudid)
Then what?
• Add PRN on top of scheduled. The PRN dose
should be about 10% of 24 hr dose (in our patient,
if morphine, that = 3mg…10% of 30mg=3mg)
• After 24 hours, calculate the total opioid dose
needed, and change to long acting preparation
*Per our example, 5mg of short acting
morphine q 4 hours = 30mg of
morphine daily….let’s say pt needed 3 PRN
doses (3mg x 3 = 9mg, so now your 24 hour
need is 39mg (about 40mg).
Then what?
• So, change to long acting morphine
(oxycontin or ms contin) 20 mg PO BID,
and keep a PRN…but since you want PRN
to be 10% of total 24 hour dose, increase
PRN to 4mg (10% of 40mg daily need) PO
q 3 hours.
What about switching from one
opioid to another?
• Must account for “incomplete crosstolerance”?…the tolerance of a currently
administered opiate that does not extend
completely to other opioids…which tends
lower the dose of the second opioid
• How much do you reduce the second
opioid?…25-50%
Example
• Patient on oral morphine 60mg BID, getting very
nauseated, vomiting…want to switch to IV
hydromorphone (dilaudid).
– Total daily dose of morphine= 120mg (60 x 2)
– Conversion of oral morphine to IV dilaudid is 30:1.5
(Google for “opioid equivalent calculator”)
– 120 = 30
x = 6mg IV hydromorphone (per 24 hrs)
X
1.5
Example (cont)
• So, the 24 dose equivalent of the previous
oral morphine is 6mg IV hydromorphone
• Divide by 25-50% to account for cross
tolerance...we’ll use 50%  so, 3mg/ 24 hrs
• To convert to hourly drip, divide 3mg by 24
hours = 0.1mg/hr
Example (cont)
• So, the patient is on 0.1mg an hour…what
do you set as the PRN dose?
– 10% of 24 hour dose (3mg) would be
0.3mg…so set that as the patient administered
dose on the PCA.
Call from 4B: “Doctor, this
patients pain is not controled”
• Just increase the drip right?
– NO! Bolus 2-3 times the current basal dose,
THEN increase the basal rate by 25-100%.
Reassess after 15-30min.
What about the Fentanyl patch?
• Use only for stable, chronic pain in patients who
are opioid tolerant, getting regular opioids > 1
week, and have requirement of at least 60mg
morphine equivalent/day
• Use the following table based on the patients
previous 24 hour opioid dose (if not on morphine,
convert to morphine equivalent)
• Don’t increase more than every 3 days
Fentanyl patch conversion
oral 24 hour
morphine
(mg/day)
30-59
60-134
135-224
225-314
315-404
Fentanyl patch
initial dose
(mcg/hr)
12
25
50
75
100
Don’t forget about constipation!
• Tolerance eventually develops for all side
effects except constipation
• “The same hand that writes the opioid,
writes the stool regimen”
– Colace AND something for motility (senna)
SCHEDULED (not PRN)…write “hold for
loose stool”
– Also add a PRN (lactulose, miralax)
Conclusion
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Treat pain
Know your pharmacology
Get to know your pharmacist
Consult the palliative care service for help
with pain and symptom management AND
for….
Reasons to consult the Palliative
care service
• Symptom management
• Help with complex decision making and
determining goals of care
– Patients with prolonged LOS without improvement
who have poor prognosis
– Patients with frequent ED visits/admissions for same
diagnosis
• Help with educating pts/families about hospice