Pain Control at the End of Life

1. Pain Control at the End of Life By Dr Marie Joseph MB BS FRCP Medical Director & Consultant in Palliative Medicine St Raphael’s Hospice, Surrey and Macmillan Consultant, Epsom & St Helier Universities NHS Trust mariejoseph@straphaels.org.uk March 2009

2. Content • Allaying ‘post-Shipman anxiety’ • Pain and distress in the dying • The WHO analgesic ladder • Principles of opioid therapy • Cardinal features of opioid toxicity • Opioid switch • Opioid equivalences • Opioids in renal failure • Providing comfort in the dying stage • Summary

3. Allaying ‘Post-Shipman anxiety’ • How much is too much? • Pressure from distressed relatives • The doctrine of double effect • Death due to disease, (not due to drug)...opposite of euthanasia • Regular, patient supervision/professional support

4. Pain and distress in the dying patient • Escalating/unabating physical pain • Emotional pain of leaving loved-ones behind • Inability to communicate • Yearning for comfort and dignity • Inevitable carer/professional distress

5. The WHO Analgesic Ladder Opioid for moderate to severe pain ± Non-opioid ± Adjuvant Opioid for mild to moderate pain ± Non-opioid ± Adjuvant Non-opioid ± Adjuvant

6. Principles of opioid therapy • Unstable pain requires titration with regular, 4-hourly, short acting opioid [same dose PRN] • Always use appropriate laxative (i.e. Softener and stimulant e.g. Movicol/Codanthramer) • Approximately 1/3rdneed anti-emetic therapy (if prone to migraine/vestibular disorder) • Increase dose by 30-50% if pain inadequately controlled (and patient not opioid toxic) • PRN dose is 1/6th of the total 24 hr dose

7. Cardinal Features of Opioid Toxicity • Excessive drowsiness • Myoclonic jerks • ‘Insect-type’ visual hallucinations • ‘Pin-point’ pupils • Caution: May be opposed by anti-cholinergic medications e.g. Cyclizine, Amitriptyline) • NOTE: Respiratory depression virtually never encountered with due vigilance as above.

8. Opioid switch Indications • Inadequate analgesia + OPIOID toxicity • Idiosyncrasy to one type of OPIOID • e.g. not uncommonly, MORPHINE OXYCODONE in neuropathic pain

9. Opioid equivalences ½ ORAMORPH 15mg [ oral Oxynorm7.5mg]  1/3 DIAMORPHINE sc 5mg  1/10 ALFENTANILsc 500mcg

10. Opioid equivalences cont.... • Durogesic (Fentanyl) 12mcg patch every 72 hours  Oramorph 5-10mg 4 hourly • Butrans patch weekly(BUPRENORPHINE) (5mcg 10mcg 20mcg) ....... Entirely STEP 2 of WHO analgesic ladder • Buprenorphine 35mcg Matrix patch (Transtec) every 72 hours or twice a week  Oramorph 5-10mg 4 hourly

11. Opioids in renal failure • Fentanyl/Alfentanilsafer • If using Morphine: Caution:  decrease dose and frequency • If using Alfentanil in CSCI (continuous subcutaneous infusion)  Dose is 1/10th of Diamorphine dose  Use Oxycodone SC prn for breakthrough analgesia

12. Providing comfort in the dying stage • PAIN  Use Diamorphine via CSCI (1/3rd of 24 hour oral Morphine dose) OR Initially 5-10mg/24 hours if Opioid Naive • RESTLESSNESS  Exclude distended urinary bladder  Attend to spiritual needs  Use Midazolam via CSCI (10-20mg/24 hours ...100mg/24hours)

13. Providing comfort in the dying stage .... Cont. • VOMITING  Use Levomepromazine via CSCI (initially 3.125-6.25mg/24 hours ......75mg/24 hours) • LUNG SECRETIONS  Use Hyoscine Hydrobromide via CSCI (initially 0.6-1.2mg/24 hours ... 2.4mg/24 hours) Note: - Regular patient review - Comfort family - Support inter/disciplinary team

14. Summary • OPIOIDS are safe and effective in the dying • Importance of familiarity with ‘Principles of opioid therapy’ • Regular patient review essential • Reassurance of Specialist Palliative Care Team support always

15. Thank you