End of Life Pain 50% of elders report “significant problems with pain” in the last 12 months of life. One-third of nursing home patients complain daily pain. Predictable, explainable pain is under treated.
Elders list pain control as one of their top 5 quality of life concerns Patients “have a legal right” to proper pain assessment and treatment.
Common Misconceptions “I should expect to have pain” “I’ll hold off so the medicine will work when I really need it” “Pain is for wimps” “I don’t want to get hooked”
Barriers We assess pain poorly and erratically We haven’t been well trained in pain management We’re afraid of addiction issues We’re afraid of mistreating the patient
Basic Approach to Pain Management Ask the patient about pain and believe them. Use a pain scale. Document what you know about the pain Reassess the pain
Nociceptive Pain Damage is to other tissue and nerve fibers are stimulated. Travels along usual pain and temperature nerves Responds well to common analgesics and opioids Sharp, throbbing, aching
Neuropathic Pain The nervous system itself damaged Direct damage to nerves, plexes, spinal cord (shingles, diabetic neuropathy) Burning, tingling, shooting May not respond as well to usual analgesics including opioids
Physical Examination motor, sensory, reflexes headaches: intracranial mass zoster, pressure sores non-verbal communication
DOSING Titrate Up Slowly Until pain controlled or side effects occur Anticipate Next Dose: tend to give a little early Use Breakthrough Doses When Needed
Extended Release Better Compliance More Expensive Dose q 8,12, or 24
Extended Release Don’t Crush or Chew May flush through feeding tubes Don’t Start with Extended Dose
Breakthrough Pain Is it new incident (new cause? or end-of-dose?) Use 10% of total daily dose (rounded up) up to q 1-2 h
Continuing Use Can continue to increase (no real upper limit) Gradually increase – Limited by Side effects Note that the effective rescue dose increases as total dose does
Other Options: Fentanyl Patch 25, 50, 75, 100 mcg/hr. Apply every 3 Days Divide Morphine Daily Dose in Half Rescue with Opioids
Other Options: Fentanyl Patch Initial Dose May Take 12- 24 hrs. May continue previous meds for 8 - 12 h If switching, remove and use rescue for 24 hrs.
Fentanyl is well absorbed across mucous membranes “Lolly-pop” approved only for breakthrough in already receiving opioids not to be chewed 200ug units not proven to be more effective than morphine concentrates
Other Options: Methadone Starts working in about 1 hr. Inexpensive Neuropathic Pain
A patient with advanced lung cancer has severe pain from a localized bony metastasis. He begins to consistent feel pain about four hours after his last dose of opioid medication. 1. According to the program which of the following would be most helpful? A. Increase medication dose B. Change medication C. Begin to give the medication at intervals of less than four hours D. Add adjuvant medication.
Answer C. A. Begin to give the medication at intervals of less than four hours
2. The most likely classification of this pain is: A. Referred Pain B. Nociceptive Pain C. Neuropathic Pain D. Visceral Pain
Problems with Opiates: Addiction Define: compulsive use, lack of control, harmful use Iatrogenic: may be as low as 1% if no previous history Avoid making this tricky diagnosis “Have you used this drug five times in your life?”
Warning signals Dominating Concerns over Availability Non-Provider Sanctioned Increases Ignoring Major Side Effects
Problems with Opiates: Dependence Defined by the occurrence of a withdrawal syndrome after reduction or cessation. May occur after only 2- 3 days of strong opioids Usually well controlled by tapering
Problems with Opiates: Tolerance Need for higher doses for same effect Can occur with effects other than analgesia Often develops faster for sedation, respiration, nausea than analgesia Slow tolerance to obstipation
Problems with Opiates: Obstipation Fluids, Bran Pericolace or Senicot-S No BM in 48 hrs: MOM or Lactulose No BM in 72 hrs: Rectal Exam; Mag Citrate, Fleets, Oil
Problems with Opiates: Nausea/Vomiting Usually occurs initially Improves with Time May be Able to Prevent with other meds, no movement
Problems with Opiates: Respiratory Depression Remember, fairly rapid tolerance develops Almost always associated with sedation Follow Respiratory Rate Withhold Next 2 Doses
Naloxone Dilute 1 Vial (0.4mg) in 10 cc. Normal Saline Give 1 cc. per minute until respiratory rate OK
Problems with Opiates: Sedation Look at Other Meds Look for Other Reasons Try Decrease Dose 25% Try another Analgesic, Psychotropic
A patient with widespread cancer is being treated with a mixed narcotic analgesic. Addition of non-narcotic pain medication for breakthrough is being considered. Which of the following is the most significant pharmacologic concern? A. Acetaminophen hepatic toxicity B. Addiction C. Tolerance D. Respiratory depression
Terminal Events Can’t Swallow: Go to Concentrate If No Urine Output: Titrate to Pain (no routine dosing)
Converting from IV to Oral Morphine, Oxycodone, Meperidine: 3 X dose Hydromorphone (Dilaudid): up to 5 X dose Then Reduce by 25% (cross tolerance)
West Virginia Schedule II. Regulations In Emergency May Telephone or Mail (60 doses) One Drug Per Prescription with MD/DO Name Printed on Blank May Fax to Long Term Care or Hospice Should Write Out Concentrations
SUMMARY Optimizing well-being of the patient and loved ones Improving control over one’s life Can reduce uncontrolled pain to less than 1 in 20. We primary care physicians can, and must, get better at this.
A patient with advanced, widespread cancer is at end-stage of her disease. She begins to experience breakthrough pain every 1 or 2 hours between doses of OxyContin. What dose should be given for rescue or breakthrough pain? A. Regular interval dose B. 10% of total daily dose C. 20% of total daily dose D. 30% of total daily dose
This patient lives many miles from the office and the Hospice nurse wished to increase the regular interval dose of medication. Which of the following is a legal option? A. Give doses of another patient’s medicine B. Fax a prescription for the regular medication to the local pharmacist. C. Give a medication on-hand not previously prescribed D. Wait until a written script can be obtained.
Answer B. Fax a prescription for the regular medication to the local pharmacist.
The patient begins to take no fluids and has instructed no IV be started. Urine output ceases. How should dosing be determined? A. Titrate to pain, using rescue dose only B. Half the usual interval dose C. Give 10% of the usual interval dose D. Double the usual interval dose.
Answer A. Titrate to pain, using rescue doses only