Presentation on theme: "Pain Control in Hospice and Palliative Care"— Presentation transcript:
1Pain Control in Hospice and Palliative Care Scott Akin MD
2Background Many patients die in pain 62-90% of children report pain at end of lifePrevalence of pain 64% in advanced cancerPain common in non-cancer (CHF, cirrhosis, HIV) patients common as well (40% w/in days of death)
3Effective pain management Three step processAssessment all types of pain (physical, emotional, spiritual)…if physical, what kind?Treat each type of pain individually, focusing on specific etiology of eachContinual reassessment of treatment goals (pain levels, goals of function, mood, sleep, social interaction, etc.)
4Determining type of Pain Nociceptive…tissue damageVisceral: 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”
5WHO 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 (codeinehydrocodone) 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.
6Adjuvants to opioids Acetaminophen (consider scheduled) NSAIDS (esp for bone mets, inflammation)Bisphosphonates (for bony pain)Steroids (for inflammation/edema)TCAs/anticonvulsants (tegretol,gabapentin) for neuropathic painLocal measures (capsaicin, lidocaine patch)
7Drugs to Avoid on Hospice/palliative Care Settings Meperidine (demerol): low potency orally, toxic metabolites may precipitate seizures & confusion. Really, only one indication for it: RigorsMixed agonist-antagonists (pentazocine): no more potent than codeine, risk of hallucination & agitation. Inhibits analgesia of morphinePropoxyphene (darvocet): no more potent than acetaminophen, toxic metabolites can precipitate seizures, confusion, cardio toxic, resp depressionDon’t give anything IM!
8Treating 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.
9More 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.
10Even 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.
11Basic 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 accountUse oral route if able (just as effective)…IV only if unable to take POs, have decreased LOC, or uncontrolled pain
12Opioid 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 % 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.
13More 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 hour5mg of short acting morphine or1mg hydromorphone (dilaudid)
14Then 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).
15Then 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.
16What about switching from one opioid to another? Must account for “incomplete cross-tolerance”?…the tolerance of a currently administered opiate that does not extend completely to other opioids…which tends lower the dose of the second opioidHow much do you reduce the second opioid?…25-50%
17ExamplePatient 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 = x = 6mg IV hydromorphone (per 24 hrs)X
18Example (cont)So, the 24 dose equivalent of the previous oral morphine is 6mg IV hydromorphoneDivide by 25-50% to account for cross tolerance...we’ll use 50% so, 3mg/ 24 hrsTo convert to hourly drip, divide 3mg by 24 hours = 0.1mg/hr
19Example (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.
20Call 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 %. Reassess after 15-30min.
21What 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/dayUse 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
23Don’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)
24Conclusion Treat pain Know your pharmacology Get to know your pharmacistConsult the palliative care service for help with pain and symptom management AND for….
25Reasons to consult the Palliative care service Symptom managementHelp with complex decision making and determining goals of carePatients with prolonged LOS without improvement who have poor prognosisPatients with frequent ED visits/admissions for same diagnosisHelp with educating pts/families about hospice