Transcript Chronic pain and palliative patient control of symptom lecture

Outline
• Definitions
• Case study “elizabeth”
• Chronic vs. palliative symptoms
• Pain
• Other symptoms
• Case study “John”
• Case study “LM”(maybe if time)
• Pump discussion and programming
• Questions and conclusion
Chronic pain and
palliative patients (1)
• Patient not
terminal
• Possible addiction
potential
• Equal tolerance
issue
• Multiple adjuvants
• Usually PO meds
• Patient terminal
• No addiction
potential
• Equal
tolerance issue
• Fewer adjuvants
used
• PO then SC meds
Chronic pain and
palliative patients (2)
• Assessment
issues
• Physician issues
• Social issues
• Similar se issues
• Team assessment
• Different dr.
issues
• Different social
issues
• Similar se issues
Chronic pain
• A pain state which is persistent and in
which the underlying cause of the
pain cannot be removed or otherwise
treated.
• Chronic pain may be associated with
a long-term incurable or intractable
medical condition or disease.
Acute pain
• Also known as warning pain, this pain is the
discomfort or signal that alerts you something is
wrong in your body.
• Pain results from any condition that stimulates the
body's sensors, such as infections, injuries,
hemorrhages, tumors, and metabolic and endocrine
problems.
• Acute pain usually abates as the underlying
problem is treated.
• Early management of acute pain may hasten the
recovery of the causative problem and reduce the
length of treatment, therefore reducing health
care costs.
Palliative pain
• Palliative pain can be described as a
mosaic combinations of pain.
• It can be from the cancer, related to
therapy, related to the cancer or
unrelated to any of the above
(arthritis, headache etc.) This can be
a mosaic of nociceptive and neurop
Tolerance
• Tolerance is a state of adaptation in
which exposure to a drug induces
changes that result in a diminution
of one or more of the drug's effects
over time.4
Addiction
• Addiction is a primary, chronic,
neurobiologic disease, with genetic,
psychosocial, and environmental factors
influencing its development and
manifestations.
• It is characterized by behaviors that
include one or more of the following:
•impaired control over drug use
•compulsive use
•continued use despite harm
•craving
Dependence
• Physical dependence is a state of
adaptation that is manifested by a
drug class specific withdrawal
syndrome that can be produced by
abrupt cessation, rapid dose
reduction, decreasing blood levels
of the drug, and/or administration
of an antagonist.
Palliative early/late
• Early refers to a palliative patient
that is still taking oral medications
and is very aware of their
surrounding.
• Late refers to a palliative patient
that is on subcutaneous
medications and not aware of
things (these are MDM terms)
WHO analgesic ladder
Non-opioid analgesics
• Aspirin, Acetaminophen
• Nsaid (non-steroidal anti-inflammatory)
Celebrex, Voltaren, Naprosyn,
Motrin, Ansaid, Mobiflex,
Feldene, Dolobid, Clinoril,
Indocid, Orudis, Toradol,
Ponstan, Ultradol, Relafen
Opioids vs. Nsaids
Opioids
Nsaids
Yes
No
Acute adverse effects
Resp. depression,
nausea, constipation
GI, renal, hepatic
Allergies
Rare
Common
Addiction risk
Potential risk
No risk
Drug interactions
Few
Many
Organ toxicity over
long-term use
None reported
GI, renal, hepatic
Titratable
Narcotics
• Codeine
• Morphine
• Hydromorphone
• Oxycodone
• Methadone
• Fentanyl
• (meperidine, propoxyphene,leritine,
levodromoran, hydrocodone, pentazocine,
butorphanol, nalbuphine)
Codeine
• Codeine is available in a variety
of forms such as: tablets,
liquid, long acting tablets and
injection. It is also available in a
combination with caffeine, ASA
or acetaminophen (Tylenol #3)
Codeine (2)
• Doses in excess of 3-4g (9-12
tablets) would be maximum
• Metabolism to morphine
• Starting doses po 15-30mg
• Dose frequency q4-6h
• PO:SC ratio 2:1
• Difficult to calculate tylenol
equianalgesic doses
Morphine
• Morphine is available as: liquid,
tablets, SR tablets, sr
capsules,suppositories,
injection.
• Non-typical forms: nose spray,
topical ointment, wound gel,
epidural, lozenge, inhalation
Morphine (2)
• Starting po dose 0.5-1mg
• PO:SC ratio 2:1
• Dose frequency q4-6H
• Triplicate prescription needed*
Oxycodone
• Oxycodone is available
commercially as: Ir tablets, Sr
tablets and combination
(Percocet)
• Non-typical forms: injection,
and oral liquid
Oxycodone (2)
• Starting dose approx. 5mg po
• PO:SC ratio 2:1
• Dose frequency q6h
• Triplicate prescription needed
• About double the strength of
morpine
Hydromorphone
• Commercially available as:
liquid, IR tablets, SR capsules,
injection (2,10,20,50mg/ml),
suppositories, and powder
• Non-typical forms: nose spray,
inhalation, sublingual tablets
Hydromorphone (2)
• Starting dose 1mg po
• PO:SC ratio 2:1
• Dose frequency q4-6h
• Triplicate prescription needed
• Five times more potent than
morphine
Methadone
• Commercially available as
tablets and liquid
• Non-typical forms: capsules,
inhalation, suppositories,
injection
Methadone (2)
• Starting dose ?????
• PO:SC ratio 2:1 but…….
• Dose frequency q????
• Triplicate required by licensed
physicians………..
• Potency 1-10X more than morpine
• Special physicians and Pharmacies
should/must be involved
• Discuss addiction use
Fentanyl
• Commercially available as patch
and injection
• Non-typical form: nose spray,
trans-mucosal device
Fentanyl (2)
• 100 times more potent than
morphine SC
• Dose frequency q1h (pump or
btp)
• Triplicate required
• Must use chart to calculate
patch dose
Dose conversion
calculations
• Daily dose PO
• Tylenol #3 (30mg) 12/day
equals how much Dilaudid (1:1
for now)
• Morpine MS contin 30mg 4/day
equals how much Dilaudid
Dose conversion
calculations (2)
• If PO Dilaudid 20mg/day, what is
the SC dose?
• If Po Morpine 200mg/day, what
is the SC dilaudid dose?
• If po morpine is 400mg/day, what
is the right Duragisic?
Duragesic dose
• 45-1342
• 135-224
• 225-314
• 315-404
• 405-494
• 495-584
• 585-674
• 675-764
25
50
75
100
125
150
175
200
765-854 225
855-944
250
945-1034 275
1035-1124 300
Adjuvant Analgesics
• Cesamet (Marinol)
• Clodronate
• Valproic acid, tegretol,
Dilantin, Neurontin, rivotril,
Topamax, Lamactil
• Antidepressants (see later)
• Corticosteroids (see later)
Nausea
• Depending on the source of the
nausea various agents can be
used.
• Vestibular
• Obstuctive
• Mind
• Infection
• Toxin
Nausea (2)
• Zofran
• Metoclopramide
• Dexamethasone
• Haloperidol
• Dimenhydrinate
• Lorazepam
• chlorpromazine
Nausea (3)
• Medications can be given orally,
topically (scopolamine, etc), SC
or rectally
• Combinations maybe needed
Dexamethasone
• PO at a dose 1-4 mg 1-2 times a
day can be used ( or sc at same
dose) for adjuvant pain as well
as nausea control
Hydration
• Normal saline
• Dextrose/saline (2/3-1/3) just
depending if carbohydrates can
be tolerated 1-2 l/day to keep a
line open
• Wydase (compounded) can be
added if not absorbing well (or
heat)
Confusion
• Haloperidol starting at doses
SC of 0.5mg and increasing to
5mg if needed
• Zyprexa and risperidal
• Sedation may need to be started
with midazolam 0.1-1mg q1h
preferably by pump
Constipation
• Be aggressive
• Start with senokot and colace
bid if needed
• Milk of magnesia, Bisacodyl ,
Fleet (oral, mineral oil,
regular), citromag, lactulose
• Erythromycin, Naloxone,
Zelnorm, etc.
Dyspnea, anorexia,
cachexia, stomatitis,
xerostomia, sedation,
secretions, seizures
• Morphine
• Megace, cesamet
• Akabutus, Nilstat, Pink-lady, diflucan
• Scopolamine
• Phenobarb, midazolam, Dilantin sups
Depression
• Very NB for chronic pain and
possibly for 1st stage palliative
but never needed in 2nd stage
Infections
• Topical infections can be
treated normally with good
wound care
• Internal infections should only
be treated orally, IV or IM
attempts should be discouraged
Gemstar pump
• Program pump to give 3mg/hour
atc and 1.5mg/hour for btp
every 20 minutes
• Review: priming, batteries,
programming, changing bag
CADD-PCA
• Program pump to deliver
1ml/hour with a 1ml bolus
every hour
• Review: programming, changing
batteries, changing bag, priming,
special problems
Other pumps
• Microject (types)
• Kangaroo
• Outbound
• Paragon
• Insulin pump types
• Medi-sys
• Abbott Provider/Aim Plus
References