Pain Control in Hospice and Palliative Care

1. Pain Control in Hospice and Palliative Care Scott Akin MD

2. Background • Many patients die in pain • 62-90% of children report pain at end of life • Prevalence of pain 64% in advanced cancer • Pain common in non-cancer (CHF, cirrhosis, HIV) patients common as well (40% w/in days of death)

3. Effective pain management • Three step process • Assessment all types of pain (physical, emotional, spiritual)…if physical, what kind? • Treat each type of pain individually, focusing on specific etiology of each • Continual reassessment of treatment goals (pain levels, goals of function, mood, sleep, social interaction, etc.)

4. Determining type of Pain • Nociceptive…tissue damage • Visceral: 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”

5. WHO 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 (codeinehydrocodone) 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.

6. Adjuvants 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 pain • Local measures (capsaicin, lidocaine patch)

7. Drugs to Avoid on Hospice/palliative Care Settings • Meperidine (demerol): low potency orally, toxic metabolites may precipitate seizures & confusion. Really, only one indication for it: Rigors • Mixed agonist-antagonists (pentazocine): no more potent than codeine, risk of hallucination & agitation. Inhibits analgesia of morphine • Propoxyphene (darvocet): no more potent than acetaminophen, toxic metabolites can precipitate seizures, confusion, cardio toxic, resp depression • Don’t give anything IM!

8. Treating 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.

9. More 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.

10. Even 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.

11. Basic 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 account • Use oral route if able (just as effective)…IV only if unable to take POs, have decreased LOC, or uncontrolled pain

12. Opioid 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 50-100% 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.

13. More 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 hour • 5mg of short acting morphine or • 1mg hydromorphone (dilaudid)

14. Then 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).

15. Then 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.

16. What 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 opioid • How much do you reduce the second opioid?…25-50%

17. Example • Patient 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 = 30 x = 6mg IV hydromorphone (per 24 hrs) X 1.5

18. Example (cont) • So, the 24 dose equivalent of the previous oral morphine is 6mg IV hydromorphone • Divide by 25-50% to account for cross tolerance...we’ll use 50%  so, 3mg/ 24 hrs • To convert to hourly drip, divide 3mg by 24 hours = 0.1mg/hr

19. Example (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.

20. Call 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 25-100%. Reassess after 15-30min.

21. What 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/day • Use 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

22. Fentanyl patch conversion oral 24 hour Fentanyl patch morphine initial dose (mg/day) (mcg/hr) 30-59 12 60-134 25 135-224 50 225-314 75 315-404 100

23. Don’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)

24. Conclusion • Treat pain • Know your pharmacology • Get to know your pharmacist • Consult the palliative care service for help with pain and symptom management AND for….

25. Reasons to consult the Palliative care service • Symptom management • Help with complex decision making and determining goals of care • Patients with prolonged LOS without improvement who have poor prognosis • Patients with frequent ED visits/admissions for same diagnosis • Help with educating pts/families about hospice