1. Palliative Pain management in the er UBC EM palliative medicine day Lindsay cohen july 27, 2016

2. Objectives Palliative pain management in the ER : Basic approach
Opioid equivalencies
Adjuvant therapies
Common pitfalls

3. Case Mr. C 65 M, single, lives alone
Hx : prostate CA widely metastatic to bone
CC : severe, diffuse pain
“Hates” the health care system – has previously declined all treatment, but came into the ED because he is now desperate
Has been going to walk-in clinics for pain meds

4. Case Pain “all over” Difficulty mobilizing over the past week
In the past 2 days, has used :
“tons” of Advil
50 x T#3 (Codeine 30 / Acetaminophen 325)
50 x Percocet (Oxycodone 5 / Acetaminophen 325)

5. Case
Can’t-miss diagnoses?

6. Case Can’t-miss diagnoses : Hypercalcemia
Malignant spinal cord compression
We’re pretty good about thinking about PE, pericardial tamponade, brain mets – consider Ca like a vital sign in cancer patients b/c it is easily missed and very treatable

7. Case Ca normal No focal neuro findings or clinical signs of SCC
You’ve decided that this is most likely pain from his bony mets
Orders?
How are you going to decide how much opioid to use?

8.
It doesn’t really matter which one you use, they will all vary slightly, just find one you like

9. Opioid Equivalencies 2 x Tylenol #3 = 10 mg PO morphine
2 mg PO hydromorphone = 10 mg PO morphine
7.5 mg PO oxycodone = 10 mg PO morphine (x oxy by 1.5)
25 mcg / h fentanyl patch = 60 – 130 mg PO morphine daily
100 mcg IV fentanyl = 10 mg IV morphine
1 mg Methadone * = 1 – 3 mg PO morphine
* Applies only to Methadone used for pain (TID), not for addiciton (daily)
These are the ones you should be quite familiar with

10. Equianalgesic Dosing
Convert current opioids to daily oral morphine equivalents (OME)
IV or SC dose = ½ of PO dose
ie. 1 mg of Hydromorphone PO = 0.5 mg Hydromorphone IV/ SC
Breakthrough dose = 10% of total daily dose
Reduce calculated dose by 25 – 50% when switching to a new opioid to account for cross-tolerance
Start low, be prepared to increase quickly

11. STEP 1 : Convert to daily OME
20 x T#3 = 100 mg PO morphine ***
25 x 5 mg Oxycodone = approx. 200 mg PO morphine
Total = 300 mg PO morphine
*** We will come back to T3s ***
*** caveat : T3s unpredictable

12. STEP 2 : IV or SC dose = ½ of PO dose
300 mg OME = 150 mg IV / SC morphine
Now convert to your desired opioid (you can do this at any point) :
150 mg morphine / 5 = 30 mg Hydromorphone

13. STEP 3 : Breakthrough dose = 10% of total daily dose
30 mg Hydromorphone daily = 3 mg Hydromorphone breakthrough

14. STEP 4 : 50% reduction for cross-tolerance
3 mg Hydromorphone breakthrough / 2 = 1.5 mg
The calculation does not have to be EXACT ; it is just to give you a rough idea of how much is reasonable, especially if they are on very high doses. In reality, it is a new opioid, and the nature of the pain may have changed, so ultimately, you are dealing with a different beast.

15. STEP 5 : Start low, be prepared to increase quickly
3 general presentations of palliative pain in the ED
Severe, acute pain crisis requiring multiple breakthrough doses within 1 h and rapid up-titration; may require an infusion
Moderate pain that is poorly controlled over the course of days – weeks despite reasonable therapy; may require IV analgesia
Mild-moderate pain that is poorly controlled but with suboptimal meds; often able to go home if med change and good follow-up

16. PATIENT 1
Severe, acute pain crisis requiring multiple breakthrough doses within 1 h and rapid up-titration
Hydromorphone 1 – 2 mg IV q 15 min PRN ; call MD if ≥ 3 doses in 1 h
If requiring multiple doses of analgesia within 1 h and still severe pain, an infusion of fentanyl would be an appropriate next step
To calculate, remember 100 mcg IV fentanyl = 10 mg IV morphine
Consult palliative!
There is no perfect “right way” to write these orders – in general, the right amount of opioid is “enough.” The keys are, be prepared to increase quickly, and make sure your nursing staff will come and get you if orders are insufficient

17. PATIENT 2 Hydromorphone 1 – 2 mg IV q 1 h PRN
Moderate pain that is poorly controlled over the course of days – weeks despite reasonable therapy; may require IV analgesia
Hydromorphone 1 – 2 mg IV q 1 h PRN

18. Talk to the RN!
DO NOT flag these orders and put them in the box to wait!
These patients are often inadequately treated :
Under-triage
Nursing discomfort with high-dose opioids / palliative care
DNR status

19. Adjuvants – Bone Pain

20. Adjuvants – Bone Pain ED MANAGEMENT Opioids
Dexamethasone (8 mg PO / SC / IV bid)
+ / - NSAIDS
OTHER CONSIDERATIONS
Radiation
Bisphosphonates
Interventional / surgical (vertebroplasty)

21. Tylenol #3

22. Tylenol #3 Hyper-metabolizers Hypo-metabolizers
Potential for Acetaminophen toxicity if patient unaware of max.

23. What’s missing from this opioid prescription?

24. What’s missing from this opioid prescription?
Bowel protocol!

25. http://www. bccancer. bc
Patients on regular opioids should always start with step 1, in addition to dietary measures.

26. Case 2 Mrs. T 73 F with lung CA metastatic to brain and bone
Diffuse pain
Followed by GP, medical oncologist, radiation oncologist, pain and symptom management team

27. Case 2 Mrs. T’s Pharmanet : Tylenol #3 1 – 2 tabs PO q4h PRN
Naproxen 500 mg PO bid
Hydromorphone ER 12 mg PO q12h
Hydromorphone 1 – 2 mg PO q4h PRN
Oxycodone 5 – 10 mg PO q1h PRN
Acetaminophen 650mg PO q4h PRN

28. Case 2 Detailed medication history / pharmacist if available
These patients often have :
Multiple providers
Multiple medications / opioids
High incidence of medication-related side effects
Misunderstanding re: role of various medications, ie. regular vs. breakthrough vs. incident pain vs. adjuvants

29. Take Home Points
Use adjuncts to opioids; in ED = Dex (bone pain, SCC, SBO)
Find out what meds patients are ACTUALLY taking (not what PNET says)
Bowel protocol with opioid Rx – always
T#3 – bad
Calcium – vital sign in cancer patients
Talk directly with RNs when dealing with unusual / high dose opioid orders

30. Summary – Rotating Opioids
Convert current opioids to daily oral morphine equivalents (OME)
IV or SC dose = ½ of PO dose
ie. 1 mg of Hydromorphone PO = 0.5 mg Hydromorphone IV/ SC
Breakthrough dose = 10% of total daily dose
Reduce calculated dose by 25 – 50% when switching to a new opioid to account for cross-tolerance
Start low, be prepared to increase quickly

31. References
The Pallium Palliative Pocketbook. 1st Edition. Pallium Canada; 2008.
Ipalapp.com. Providence Health Care Hospice Palliative Care Program
BC Cancer Agency Constipation Protocol. oncology-network-site/Documents/SuggestionsforDealingwithConstipation.pdf
Palliative Medicine in the ED. Galicia-Castillo MC et al. emedjournal.com. August 1, 2015.