Management of Pain in Patients at End-of-Life Junior Rotation in Hospice and Palliative Care

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Management of Pain in Patients at End-of-Life
Junior Rotation in Hospice and Palliative Care

• This work was produced by the University of
  Maryland Palliative Care Educational Initiative,
  which is funded by an R25E grant from the NCI.

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Overall message

• Pain management is an essential component of
  comprehensive medical care

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Pain requiring opiates in cancer gt70 of
advanced cases

• Pain due to cancer
• Oral thrush, HSV
• Esophagitis
• Neuropathic pain
• Radiculopathy, plexopathy
• Bone pain
• Mets, pathol. Fractures
• Tumor mass
• Etc.

• Pain due to treatment
• Mucositis
• Esophagitis
• Neuropathy
• Neurotoxic drugs
• Bone pain
• Avascular necrosis, osteoradionecrosis
• Post surgical pain
• Etc.

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CANCER PAIN

• MOST COMMON SYMPTOM
• MOST EMOTIONAL SYMPTOM

• MOST COMMON SYMPTOM
• MOST EMOTIONAL SYMPTOM
• MOST TREATABLE SYMPTOM

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Cancer pain remains undertreated today

• Patients with metastatic cancer and severe pain
• 42 were NOT GIVEN ADEQUATE PAIN THERAPY!
• Cleeland, et.al., NEJM 330592-6, 1994

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Essentials of pain management

• BATS
• Barriers
• Assessment
• Treatment
• Side effects

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BarriersAssessmentTreatmentSide Effects

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Problems Related to...

• The health care and legal system, e.g.,
• Triplicate prescription forms
• Health care professionals e.g.,
• Lack of training, value
• Fear drug diversion, patient addiction
• Patients e.g.,
• Do not report pain
• Fear of addiction

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Narcotic Addiction

• ADDICTION IS
• Psychological dependence
• Use other than pain control
• Desire to get high
• ADDICTION IS NOT
• Physical dependence
• Withdrawal upon drug removal
• Tolerance

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Use vs. Abuse

• More Suggestive of Addiction
• Selling prescription drugs
• Prescription forgery
• Stealing drugs from others
• Injecting oral formulations
• Obtaining prescription drugs from non-medical
  sources
• Concurrent abuse of alcohol or illicit drugs
• Repeated dose escalations or similar
  noncompliance despite multiple warnings
• Repeated visits to other clinicians or emergency
  rooms without informing prescriber
• Drug-related deterioration in function at work,
  in the family, or socially
• Repeated resistance to changes in therapy despite
  evidence of adverse drug effects 
• Intense expressions of anxiety about recurring
  symptoms.

• Less Suggestive of Addiction
• Aggressive complaining about the need for more
  drugs
• Drug hoarding during periods of reduced symptoms
• Requesting specific drugs
• Openly acquiring similar drugs from other medical
  sources
• Occasional unsanctioned dose escalation or other
  noncompliance
• Unapproved use of the drug to treat another
  symptom
• Reporting psychic effects not intended by the
  clinician
• Resistance to a change in therapy associated with
  intolerable adverse effects

Adapted from Portenoy, RK Opioid therapy for
nonmalignant pain. In Fields HL, Liebeskind JC,
eds Pharmacological Approaches to the Treatment
of Chronic Pain New Concepts and Critical
Issues. Progress in Pain Research and Management,
Vol. 1. Seattle, IASP Press, 1994, p 267. Taken
from Portnoy, RK Contemporary Diagnosis and
Management of Pain in Oncologic Patients, Second
Edition. Newtown, PA. Handbooks in Healthcare
Co., 1998, p 35.
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BarriersAssessmentTreatmentSide Effects

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Types of Pain

• Nociceptive
• Somatic bone/soft tissue tender, deep,
  aching
• Visceral spasms, cramping
• Deafferentation or neuropathic
• shooting, stabbing, burning paresthesias,
  hypesthesias, allodynia

Opioid Receptors spinal cord Ksupraspinal
Muboth Delta
Neuropathic Pain damage to nerve X
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Acute vs. Chronic Pain

• Acute Pain
• Follows injury...resolves
• Objective physical signs--COMMON
• Chronic Pain--cancer, term. illness
• Objective signs RARE
• Patients may not look like they are in pain

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Pain Assessment

• Believe the patients report of pain
• Take a careful pain history
• 5th vital sign Pmax?, P current?
• constant vs. episodic?
• location, quality?
• effects on mood, ADL sleep, eating or moving
• Have patient quantitate the pain

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Pain rating scales
Categorical scale
0 No pain
1 Mild
2 Discomforting
3 Distressing
4 Intense
5 Excruciating
Visual analogue scale
No pain
Most pain
Numeric rating scale
( 0 No pain, 10 Worst pain imaginable )
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Pain Assessment, Contd

• Perform a physical examination
• Review pertinent labwork
• Treat the pain while completing the diagnostic
  evaluation
• Determine the cause of pain, use
  diagnosis-specific therapy
• Reevaluate frequently

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BarriersAssessmentTreatmentSide Effects

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The W.H.O 3-step Pain Ladder

• Step 1
• non opioid adjuvant
• Step 2
• weak opioid step 1 meds
• Step 3
• strong opioid step 1 meds

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Controlling SEVERE PAIN

• Goal
• Acceptable relief of pain with
• Acceptable side effects

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Around-the-Clock DosingBest way to manage
chronic pain
From Whitten, Donovan, Cristobal. Treating
chronic pain new knowledge, more choices. The
Permanente Journal 2005 9 9-18.
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Interventions Severe pain

• Stabilize the patient on short acting opiate
• Revaluate at time of peak analgesia
• Oral 1 hour
• IV 10-15 min
• Use IV opiates initially if necessary
• Convert to long acting opiates after
  stabilization--round-the-clock schedule

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Severe Pain, contd...

• Drugs of choice--full agonists (??
• Morphine, Oxycodone, Hydromorphone
• Effective orally, IV and SubQ!
• oral morphine 3 x IV dose
• Elimination half life 3 hr
• Peak analgesic effect Oral 1 to 2 hrs
  IV 15 min
• Duration of analgesic action 3 to 4 hr
• Maintenance dose interval Q4H

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Severe Pain, contd...

• Starting oral doses
• Morphine 15-30 mg
• Oxycodone 10-20 mg
• Hydromorphone (Dilaudid) 4-8 mg

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TITRATION END POINTS

• Repeat dose or titrate upwards (may increment
  50-100) every 1 to 2 hours until either
• adequate analgesia is reached (gt50 reduction in
  pain)
• OR
• side effects are encounteredeg., sedation
• No ceiling dose for titration

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Sustained-Release Oral Opioids

• Preparations available
• Morphine (MS Contin, Oramorph SR, Kadian)
• - starting dose 20-30 mg PO q12h
• Oxycodone (Oxycontin)
• - starting dose 20 mg PO q12h
• Steady-state reached by 24 hours
• Can be titrated q24h for unrelieved pain
• Moderate increase by 25-50 q 24h
• Severe increase by 50-100 q24h

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The Fentanyl Patch (Duragesic)

• No analgesic effect for 12-24 hrs!
• Steady state only after 72 hr--therefore
• Replace or increment every 72 hr
• Do not use for initial dose titration!
• Fentanyl levels decay with half-life of 17 hrs
  after removal of a patch
• Need Breakthrough medication
• One 25 ?g/hr patch 60 mg morphine/day

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Opioids to Avoid

• Demerol
• Dose ceiling--toxic metabolite, nor-meperidine
• Short duration of action--2 to 3 hrs
• Only effective IM or IV
• 50 mg Demerol PO 625 mg Aspirin
• Mixed Agonist-antagonists
• Talwin, Nalbuphine, Butorphanol, Buprenorphine

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Breakthrough Pain

• Idiopathic / spontaneous
• Disease progression
• Incident
• End-of-dose failure

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Breakthrough Treatment

• Use immediate acting opioid
• Morphine sulfate
• Oxycodone
• Hydromorphone
• Prescribe 1/6 of total daily ATC opioid dose
• Breakthrough freq Q1-2H PRN

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Non-opioid adjuvants

• Pain types with poor opioid response
• Neuropathic pain
• ADD Tricyclic antidepressants
• ADD Anticonvulsants
• Bone pain
• ADD NSAIDs
• Edema
• ADD steroids

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BarriersAssessmentTreatmentSide Effects

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Side effects Constipation

• Plan on it!
• Tolerance doesn't happen
• Adjust the dose of laxative/softener with
  adjustments in opioid dose
• Need senna, bisacodyl, sorbitol
• Keep asking about their bowels

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The hand that writes the opioid order shall also
write the laxative order!

• quote from the Canadian palliative care curriculum

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Side Effects Respiratory Depression

• Tolerance usually develops quickly
• Sedation before respiratory depression
• Risk factors
• Opioid naïve
• IV administration
• Rapid dose escalation
• Removal of painful stimulus
• Relative risk chronic lung disease (CO2
  retention), renal dysfunction

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Other Opioid Side Effects

• Nausea
• Myoclonus (with very high doses)
• Pruritis
• 2o opioid-induced histamine release
• Urinary retention

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Essentials of cancer pain management

• BATS
• Barriers
• Assessment
• Treatment
• Side effects

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Questions?