Pain Management in The Hospice Setting

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1 Pain Management in The Hospice Setting Jerry L Old MD Associate Professor & Geriatrics Clerkship Director University of Kansas School of Medicine jold@kumc.edu Regional Medical Director Hospice Care of Kansas

2 Evidence Based!

3 Frustration Doomed if we do and Doomed if we don t Concerns of Over-Prescribing Incidence of Abuse and Diversion of Prescription Medications is Increasing Schneider-phobia Concerns of Under-Prescribing Patient Suffering can be relieved Ethical Issues

4 Pain Treatment The Problem Studies since 1950 s all show undertreatment of Pain 40% cancer patients under-treated Patients afraid to talk to their Physicians about Pain 45-80% of Nursing Home Residents report some pain every day!

5

6 Treatment Not treating pain comes dreadfully close to inflicting it!

7 Objectives (Evidence Based) Demographics Incidence and assessment of pain Myths about pain medications and treatment Addiction, tolerance, and dependence Specific pain medications Side effects/legal Issues

8

9 Demographics Average life-span in yrs Average life-span in 2000 White Females 84.2 years Black Females 82.3 years White Males 81.1 years Black Males 79.3 years Dept Health and Human Services

10 Demographics Over 85 years is now the fastest growing segment of our population! By 2050 there will be approximately 1.1 million people 100 years or older!

11

12 Stages of Life!

13 Geriatric Medicine Principle of Compressed Morbidity We don t expect our patients to live forever Push back the time of impairment

14 Pain Management Acute Pain Identified event Resolves in days/weeks Usually identifiable physiologic reason Resolves Chronic Pain (Geriatrics) Cause often not easily identified Indeterminate duration (<6 mo.) Do not expect it to resolve with time

15 Pain (Evidence Based) Pain impacts the quality of life Any pain that has an impact on physical function, psychosocial function, or other aspects of quality of life should be recognized as a significant problem. Strength of Evidence 2A (National Guideline Clearinghouse)

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17 Historical Perspectives Dying has become more complex, and takes longer We have Created Chronic Disease Average of 30 Months Corr CA, Death In Modern Society. Oxford Textbook of Medicine 2 nd ed., Doyle editor, Oxford University Press, 1998,pp

18 Assessment of Pain An appropriate medical evaluation should be recorded in the chart Use standard verbal pain reports of pain quality and intensity Do frequent charting of pain level and response to treatments Record FUNCTION! Physical Psychosocial Quality of life

19 Assessment of Pain Pain is what the patient tells you it is!

20 Numerical Pain Scale Wong Pain Scale

21 Assessment of Pain Pain is a diagnosis Don t wait to treat pain

22 Evaluation of Pain in Dementia Requires Baseline knowledge of the patient s typical behavior! Agitation Dyspnea Restlessness Insomnia Grimacing Pacing Aggression Nausea Anorexia

23 Factors Causing Pain in EOL Pain should be anticipated and ASSUMED to be present in patients with a disease or injury known to cause pain Terminal Illness Cancer Dyspnea Decubitus Constipation Procedures Surgery Respirator/Intubation Musculo-Skeletal Disorders Fractures Arthritis Contractures

24 Pain Assessment (Evidence Based Practice Recommendation) For older adults with cognitive impairment unable to report pain, assess for the presence of factors that cause pain National Guidelines Clearinghouse Evidence Level B

25 Accessing Pain in the Geriatric Patient Initiate an analgesic trial. If behavior returns to typical for that patient, it is likely that pain was the causative factor.

26 Quality of Pain Somatic: dull/aching, well localized; fracture or bone met Visceral: dull/sharp/colicky, well localized or referred; gastritis, gallstones Neuropathic: burning, lancinating, numbness or hyperesthesia; PHN, DM, Spinal Disc

27 Barriers

28 Misconceptions of Patients Pain is punishment for past transgressions Pain is indicator that death is near or serious disease is present Acknowledging pain means extensive intrusive testing or loss of independence

29 Misconceptions of Patients Pain is inevitable part of aging Pain is a sign of weakness

30 Aging Super Heroes

31 Misconceptions of Physicians (Data) Adequate pain control is often just impossible Morphine (or other pain medications) cause serious respiratory depression Higher tolerance for pain in the elderly Older People do not Need Anesthesia for Dental Extractions Lancet 1933

32 Misconceptions of Pain Control (Emotional) Addiction is a serious problem in pain control Physicians frequently get into legal problems when prescribing pain medications

33

34 Pain Management Fear of Addiction!

35 Pain or Addiction? Evidence Based Practice Recommendation Practitioners must recognize the difference between drug addiction, tolerance, and dependency, to prevent these from becoming barriers to optimal pain relief. Systemic evidence review: National Guideline Clearinghouse Strength of Evidence A &nbr=005960&string=pain+and+barriers#s23

36 Pain or Addiction? Definitions: Tolerance is the need to increase the amount of drug to obtain the same effect. Alcohol Laxatives Uncommon in opioids used for pain management If dose is increasing, suspect disease progression!

37 Pain or Addiction? Definitions: Physical Dependence: development of withdrawal reaction upon discontinuation or antagonism of the drug. Very Common Benzo s Beta Blockers Clonidine Steroids Insulin

38

39 Pain or Addiction? Definitions: Pseudoaddiction-behavioral manifestations of addiction occurring as a result of under treated pain; typically in the setting of severe continuous pain when drugs are administered at inadequate doses at excessive dosing intervals

40 Pain or Addiction? Definitions: Addiction-a.k.a Psychological dependenceoverwhelming involvement in the acquisition and use of drugs for non-medical purposes (diversion). Tolerance and physical dependence may or may not be present. The presence of tolerance or physical dependence does not prove psychological dependence

41 Addiction... Simple Definition-- Continued use of drugs in spite of harm A rare outcome of pain management particularly, if no history of substance abuse Nedeljkovic SS, Wasan A, Jamison RN Clinical Journal of Pain, 2002

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43 Pain or Addiction? Evidence Based Practice Recommendation The fear of Addiction should not be a barrier to the adequate treatment of Pain. Systemic Evidence Review: Bandolier acpnconc.html

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45 Pain Management It is estimated that 5-10% of patients have variants of the deep brain structures that facilitate the reinforcement and reward system that predisposes them to addiction. Often includes history or family history of drug or alcohol abuse Major Psychiatric disorder Fine PG, Portenoy RK A Clinical Guide to Opioid Analgesia 2004

46 Balance Balanced Policy Recognizes that opioids are necessary for relief of pain They should be accessible to patients who need them for legitimate medical purposes Controls are necessary to prevent diversion and abuse. Pain & Policy Study Group Achieving balance in federal and state pain policy: guide to evaluation 2007

47 Pain Management The risk of adverse effects associated with long term opioid therapy in patients without a history of substance abuse, is relatively low. Nedeljkovic SS, Wasan A, Jamison RN Clinical Journal of Pain, 2002

48 What Works?

49

50

51 Non-Pharmacologic Treatment Comfortable, safe environment Minimal noise and stimulation Clean and dry Backrub, shower, bath Touch Manipulation Reassuring words Talk to pastoral counselors, caregivers Physical Therapy Chiropractic

52 Pharmacologic Management Choice of analgesics should be based on the patients report of pain Should follow the World Health Organizations 3 step ladder approach to pain management

53 Analgesic Ladder Strong Opioids Weak Opioids Morphine, Fentanyl Hydromorphone Non-Opioids Acetaminophen, NSAID s, COX-2 Oxycodone, Hydrocodone, Codeine World Health Organization 1990

54 Management Routes of Administration: Oral Route is the preferred route of analgesic administration Reasonable alternatives include buccal, sublingual, rectal and finally subq routes I.M route should be avoided as it is more painful I.V. is preferred if parenteral route necessary (PCA) Others: Epidual, Intrathecal etc.

55 Step 1 Analgesics Mild Pain Acetaminophen NSAIDS/ASA Cox-2 Inhibitors Tramodol Propoxyphene

56 Acetaminophen Why is Tylenol, the pain reliever recommended by most doctors? Site, mechanism of action unknown Doesn t affect stomach, kidney, platelets But, it has no inflammatory mediators And, it has a ceiling dose: 4 Grams/24 hours And is hepatotoxic in overdose

57 Checkpoint What is the dose of acetaminophen in the following preparations: Lorcet Plus Vicodin ES Ultracet

58 Checkpoint Lorcet Plus = 650 mg acetaminophen Vicodin ES = 750 mg acetaminophen Ultracet = 325 mg acetaminophen

59 NSAIDs Decreases levels of inflammatory mediators Synergistic analgesia with opioids Has significant end organ toxicity Should be used with great caution in the elderly 7,600 deaths, 76,000 hospitalizations in 1997 due to adverse effects from NSAIDS

60

61 Tramadol (Ultram ) A synthetic non-opioid analog of codeine; it is a mu-receptor agonist Analgesic effect roughly equivalent to Tylenol #3 Efficacy variable; has an analgesic ceiling No anti-inflammatory effects Side effects similar to opioids at high dose-- nausea, confusion, dizziness, constipation Dependence may occur

62 Not recommended... Propoxyphene No better than placebo in some studies; Equipotent to ASA in others low efficacy at commercially available doses Toxic metabolite at high doses propoxyphene is not recommended for pain in most national pain guidelines!

63 Pain

64 Opioid Analgesics Moderate to Severe Pain Step 2 Weak Opioids Codeine Hydrocodone Oxycodone Step 3 Strong Opioids Morphine Fentanyl Hydromorphone Methadone

65 Pain Therapy Codeine Codeine is inactive and needs to be converted to morphine which is the active analgesic 10% of population do not have the enzyme necessary to activate codeine Most constipating and most emetogenic of opioids

66 Opiod Analgesics Moderate to Severe Pain Opioids All opioid analgesics produce pain relief via interaction with opioid receptors in the brain/spinal cord and perhaps via peripheral opioid receptors The mu receptor is the dominant analgesic receptor, but other receptors play a role in analgesia for certain opioids There is no dose ceiling for opioids, only for acetaminophen in combination products

67 Opioids (cont) Opioids are classified by their interaction with the opioid receptors pure agonist (morphine, hydromorphone oxycodone, codeine, meperidine, fentanyl) mixed agonist-antagonist (butorphanol, pentazocine, nalbuphine) partial agonist (buprenorphine) pure antagonist (naloxone, naltrexone)

68 OPIOIDS Duration of Action

69 Short Acting Opioids Parenteral or Oral morphine hydromorphone meperidine codeine Oral only oxycodone hydrocodone Note: hydrocodone is only available as a combination product.

70 Short Acting Opioids Oral dosing: onset in min peak effect in minutes duration of effect 2-4 hours Can be dose escalated or re-administered every 2-4 hours for poorly controlled pain as long as the daily Acetaminophen dose stays < 4 grams Dosing should not exceed 4 hrs

71 Equianalgesia All potent opioids will produce the same degree of analgesia if provided in equianalgesic doses. Thus, there is little basis to say, morphine did not work, but hydromorphone did work. Such a statement generally means that non-equianalgesic doses were used. There is no dose ceiling.

72 Equianalgesia Common Conversions 10 mg IV MS = 30 po MS 10 mg IV MS = 1.5 mg IV hydromorphone 30 mg po MS = 7.5 mg po hydromorphone 30 mg po MS = 30 mg po oxycodone ** Note: Conversions factors are only a rough guide to approximate the correct dose. ** Controversial: some recommend 3:2 or 2:1 ratios for MS: oxycodone

73

74 Long Acting Opioids It is better to stay AHEAD of the pain Long acting preparations are recommended in any chronic pain, particularly end-of-life situations

75 Long Acting Opioids Oral Long acting Morphine Long acting Oxycodone Methadone Transdermal Fentanyl Patch All must be taken intact they cannot be crushed; they do not fit down GI tubes.

76 Long Acting Opioids All provide 8-12 hours of analgesia Minimum dosing interval is q 8 hours All provide onset of analgesia within 2 hours All can be dose escalated every 24 hours

77 Transdermal Fentanyl Slow onset of action: hours Duration of action: hours Should only dose escalate q 3 days Fentanyl stays in circulation for up to 24 hours after patch removal Place on hairless, non-irradiated skin No ceiling dose No evidence that effectiveness is decreased by cachexia

78 Management Other Medications Methadone very good and also cheap; has problems with dose adjustment Long Half Life Half life is longer than the analgesic effect! Dose conversions to: from other opioids are complex seek consultation Lidocaine patches

79 Not recommended... Meperidine Poor oral absorption Weak potency; 300 mg PO= 10 mg IV morphine Shortest acting (only 2-3 hr duration) Normeperidine is a toxic metabolite longer half-life (6 hours), no analgesia CNS-stimulant; Tremor, myoclonus, seizures if dosing q 3 h for analgesia, normeperidine builds up accumulates with renal failure

80 Meperidine Recommendations Only indicated for short term, procedural pain NO more than 48 hour course NO more than 600 mg (parenteral) within 24 hours No evidence to support the use of meperidine as the drug of choice for biliary or pancreatic pain sickle cell pain

81

82 Breakthrough Pain Patients on any long-acting med always need a second, short-acting med, available for breakthrough pain something they can take at least every 4 hours, preferably less Guideline, dose of breakthrough opioid should be: 10-20% of 24 hour dose of analgesics and made available q2 hours

83 Opioid Dose Escalation Always increase by a percentage of the present dose based upon patient s pain rating and current assessment % increase 25% increase 25-50% increase Severe pain 7-10/10 Moderate pain 4-6/10 Mild pain 1-3/10

84 Opioid Good News Very effective analgesics Relieve anxiety/air hunger Improve mood No evidence of major organ toxicity with long term use No clinical evidence of long lasting changes in CNS

85 Pain Therapy Neuropathic Pain Responds poorly to opioids Gabepentin (Neurontin) Pregabalin (Lyrica) Topical Lidocaine Additional Agents TCA SNRI

86 Side Effects

87 Side Effects of Opioids Common Nausea/Vomiting Constipation Sedation Less Common Confusion Myoclonus Dry Mouth Urinary Retention GERD Rare Respiratory depression (Very rare in properly titrated patients)

88 Nausea and Vomiting Morphine and codeine are the most emetogenic opioids Nausea is not an allergy!! Tolerance develops within 3-7 days for most patients Standard anti-emetics can reduce symptoms

89 Treatment of Common Side Effects Nausea/Vomiting Time (Tolerance in 3-7 days) Haloperidol mg Prochlorperazine (Compazine) 5-10 mg Metoclopramide mg Ondansetron (Zofran) not as effective! Constipation (No tolerance develops) Stimulants Senna Bisacodyl Dulcolax supp Enemas

90 Constipation Multi-factorial cause Tolerance does not develop Start a bowel stimulant at the time opioids are started Senna or MOM good first choices Goal is one BM qod

91

92 Management The finger that holds the pen to write for the Opioid, must also hold the pen to write for the laxative or that finger will be used to dis-impact the patient!

93 Sedation / Respiratory Depression With increasing dose, all opioids lead to a predictable sequence of CNS events: Sedation with or without delirium then Further decrease consciousness then Coma and respiratory depression

94 I don t want to be the last one that gives the Morphine!

95 Double Effect What is the INTENTION or GOAL of the treatment?

96 DEA Position on Opioids for Pain Management It is the position of the Drug Enforcement Administration that these controlled substances should be prescribed, dispensed, or administered when there is a legitimate medical need. DEA s Physician Manual p. 21

97

98 Good Pain Management Everyone has to be comfortable with their own individual threshold of treating pain. Base our threshold on FACTS and NOT MYTHS Tolerance, Withdrawal, Addiction Patient will stop breathing (pt s don t go from awake to dead!) Side effects Constipation (same finger that holds the pen ) Worried about being taken--diversions

99 Universal Precautions in Pain Management Document Set goal and put in Progress Notes Involve your entire team Treatment Agreement (Pain Contract) Recognize Suspicious Behavior Record Function Reassess often Use Pain Medications Appropriately

100 The Consultants

101 Kansas Board of Healing Arts Physicians should not fear disciplinary action from the Board for prescribing, dispensing or administering controlled substances, including opioid analgesics, for legitimate medical purpose Approved October 17 th, 1998

102 Summary Continuous pain at the end-of-life requires continuous pain treatment Prescribe opioids with a fixed dose and interval that makes pharmacological sense Use oral dosing Prescribe short acting opioids q 4 hours (not q6, q8, q12) Use long acting oral agents when possible Pt should have a short acting opioid for breakthrough pain Avoid Ranges

103 Our Patients Want to Remain Active It s Our Job to Help Them!

104 References Old J, Swagerty D. A Practical Guide to Palliative Care, 2007, Lippincott. Acute Pain Management Guideline Panel. Acute pain management: Operative or Medical Procedures and Trauma Clinical Practice Guideline. AHCPR Publication No Rockville, MD. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service, Breitbart W, Chandler S, Eagle B, et al. An alternative algorithm for dosing transdermal fentanyl for cancer pain. Oncology 2000:14: Fohr SA. The double effect of pain medication: separating myth from reality. J Pall Med 1998; 1: Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication No Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, Portenoy, RK. Chronic Opioid Therapy in Nonmalignant Pain. J Pain Symptom Manage 1990; 5: S46-S62.

105 References (cont) Methadone for Cancer Pain. Morphine by mouth is an effective pain killer for cancer pain. Pain Managenment. Emory University School of Medicine.

106

107 Cases Case 1. Mrs. D is a 67 year old attorney who has breast cancer metastatic to bone. She is currently hospitalized and after several failed attempts at pain control, is comfortable on a continuous infusion of morphine at 6 mg per hour. The patient s wish is to be at home for the remainder of her days. She and her family have decided to do comfort care at home. Your goal is to change to oral medications as she wants to be discharged home on Hospice. Her husband is afraid she will become addicted to the morphine, or stop breathing if she takes too much. What will be your advice and dose of medications to change her to?

108 Pain Management Morphine 6 mg IV x 24 hours = 144 mg/24 hrs

109 Pain Management Morphine 6 mg IV x 24 hours = 144 mg/24 hrs Conversion to oral Morphine = 30 mg PO = X mg PO 10 mg IV 144 mg IV 3 to 1 ratio It takes 3x as much PO as it does IV!

110 Pain Management Morphine 6 mg IV x 24 hours = 144 mg/24 hrs Conversion to oral Morphine = 30 mg PO = X mg PO 10 mg IV 144 mg IV 10X = 30 x x = 4320 X = 432 mg PO in 24 Hours X=432 mg oral Morphine Equivalent in 24 hours

111 Pain Management 432 mg oral Morphine Equivalent in 24 hours 216 mg (200 mg) MS Contin (Long Acting) q 12 hours 144 mg q 8 hours What Else????

112 Pain Management Breakthrough 10-20% Daily Morphine dose 43 mg (40) to 86 MG (80) Q 2 Hours PRN What Else???

113 Pain Management Hydromorphone (Dilaudid) 30 mg MS PO = 432 Mg MS PO 7.5 mg Dilaudid PO X Mg Dilaudid PO 30 X = 432 x X = 3240 X = 3240/30 X = 108 MG Dilaudid PO

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