Pain Management in the Terminally Ill Patient Myths, Misinformation, and Mistakes

1. Pain Management in the Terminally Ill Patient Myths, Misinformation, and Mistakes David M. McGrew, MD Diplomat, American Academy of Pain Management Diplomat American Board of Hospice and Palliative Medicine

2. Terminally Ill - Defined • Acute or chronic illness • Prognosis less than 1 year (state) • Prognosis less than 6 months (Medicare hospice)

3. There Is a Problem

4. Attitudes, Beliefs, and Practices Skills and knowledge Myths and misinformation Detrimental attitudes

5. Pain Defined Unpleasant Somato-Psychic Experience NO FUN It affects the mind It is what the patient says it is It originates in the body (most of the time)

6. Prevalence • 80% of cancer patients • 34% have more than 4 identifiable pains PAIN “SIMPLE” NO PAIN “COMPLEX”

7. TOTAL PAIN SOMATIC INPUT ANXIETY ANGER / EMOTION DEPRESSION

8. TOTAL PAIN Somatic Inputs • Related to Cancer • Related to Treatment • Unrelated to Cancer or Treatment

9. Bone Infiltration Muscle Infiltration Nerve Compression Nerve Infiltration Visceral Involvement Soft Tissue Infiltration Ulceration / Infection Intracranial Pressure Constipation Bed Sores Lymphedema Candidiasis Herpetic Neuralgia DVT PE ……. TOTAL PAIN Pain Related to Cancer

10. TOTAL PAIN Pain Relatedto Treatment • Post-Op Acute Pain / Neuralgia • Phantom Limb Pain • Post-XRT Inflammation / Fibrosis / Myelopathy / Osteonecrosis • Post-CMTX Neuropathy / Soft Tissue Necrosis • …….

11. TOTAL PAIN Pain Unrelated toCancer or Treatment • Low Back Ache (muscular) • Headache (tension, migraine) • Angina • …….

12. TOTAL PAIN Depression • Loss of social position • Loss of job • Loss of role in family • Chronic fatigue • Insomnia • Helplessness • Disfigurement

13. TOTAL PAIN Anger / Emotions • Bureaucratic bungling • Friends who do not visit • Delays in diagnosis • Unavailable doctors / nurses • Unresponsive doctors / nurses • Therapeutic failure • Uncontrolled symptoms

14. TOTAL PAIN Anxiety • Fear of hospital or nursing home • Worry about family • Fear of death • Spiritual unrest, guilt • Fear of pain • Family financial worries • Loss of control • Uncertainty about future

15. Patients Needs • Permission to admit fears • Open discussion of thoughts and feelings • Accurate information • Participation in treatment • REALISTIC hope • Consistency and availability

16. Narcotics as the Only Response • Bone Pain • Prostaglandin Mediated • Responds well to NSAID’s • Neuropathic Pain • Steroids, Tri-cyclics, Anti-convulsants

17. Other Narcotic Resistant Pains • Deafferentation • Headaches • Muscle Spasm • Tenesmoid (Bowel / Bladder) • Incident to movement • Decubitus

18. Physiology of Pain • Pain Receptors • Ascending Pathways • Descending Pathways • Neurotransmitters • Gate Control (competitive)

19. A Test for Every Pain History Physical Exam Diagnostic Testing Diagnostic Testing Testing, invasive or not, should only occur where the results will significantly alter the course of treatment. In a terminally ill population, the burdens of testing often outweigh the benefits. - STOP AND THINK

20. History • Separate each site of pain • site • quality • timing • radiation • severity • aggravating / palliating factors • impact on sleep, mood, function

21. Physical Examination • Active and Passive Range of Motion • Allodynia / Hyperesthesia • Tenderness

22. Diagnostic Testing JUST SAY NO

23. Inadequate Dosing • How do you know? • The patient is still in pain ! • When have you gone too far? • Side effects outweigh benefits ! • (notice no comment on dose)

24. McGrew's Maxim Narcotic Equivalence • 10 mg Hydrocodone = 10 mg Oxycodone = 10 mg Morphine = 1 mg Hydromorphone = 100 mg Meperidine = 120 mg Codeine • 1 mg sc/im/iv = 3 mg po

25. Principles of Dosing • Prevent Pain - Don’t Chase It • Give enough RTC that PRN < 3 doses/day • Give equivalent daily dose RTC and PRN • If using MSO4 180 mg daily RTC (60 mg q 8h) then allow up to 180 mg daily in “rescue” dosing (30 mg q 4h)

26. Multiple Narcotic Agonists • More medications = More side effects • Multiple mixed agonists = Too much Acetominophen • Agonist / Antagonist Withdrawal

27. Give ‘em a shot! • Preferred Routes • Oral • Rectal • ? Transdermal • SC • IV • Epidural • Intrathecal • IM

28. Other Principles of Therapy • Allow patient control • Focus on whole family • Address non-medical issues (spiritual, social) • Treat other symptoms (constipation, nausea, dyspnea) • Consider best environment • Never use placebo • Get help if needed

29. Unwarranted / Exaggerated Fears • Respiratory Depression (Narcan) • Addiction • Rapid Tolerance • Regulatory Reprisal • DEA • DPBR

30. Apathy Attitudes • Real or Perceived ? Science may have found a cure for many evils; but it has found no remedy for the worst of them all - the apathy of human beings. Helen Keller (1880-1968)

31. Accusation Attitudes • Drug Seeker • Addict • Wimp • Hypochondriac

32. Schweitzer on Pain We all must die. But if I can save him from days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.

33. AHCPR Guidelines :Management of Cancer Pain (800) 4-CANCER

34. AAHPM American Academy of Hospice and Palliative Medicine UNIPAC Three : Assessment and Treatment of Pain in the Terminally Ill