Pain Management in Palliative and Hospice Care Donna Butler, MSN, ANP-BC, OCN, ACHPN, FAAPM Current Status of Pain Cancer patients at EOL- 54% have pain AIDS with prognosis < 6mons- intense pain Less research conducted in other chronic illness Inadequate pain relief hastens death physiologic stress mobility (risk of pneumonia, & thrombus) Pain relief is essential at end of life Allows patient to let go Barriers to Pain Relief Importance of discussing barriers Specific barriers Professionals Inadequate knowledge, poor assessment, concerns about regulations, fear of addiction Health Care systems Inadequate reimbursement, restrictive regulations, availability of treatment Patients/families Reluctant to report pain, concern will distract MD from treating dx., fear what pain means, fear of addiction, lack of adherance. PAIN VIDEO Pain Assessment Physical exam Pain history Neurological exam Laboratory/diagnostic evaluation Reassess Common Pain Syndromes at End of Life Nociceptive Somatic-arthritis, bone mets.(localized) Visceral-ascites, tumor,(not well localized) Neuropathic Post herpetic neuropathy Diabetic neuropathy HIV associated neuropathy Chemotherapy related neuropathy 1
Pain Syndromes Pain associated with the cancer Bone metastases Pain associated with cancer treatment Post surgical syndromes Chemotherapy-induced neuropathies Radiation induced damaged Pain unrelated to cancer or its treatment Existing syndromes (e.g. diabetic neuropathy) Pain: A Multidimensional Phenomenon Functional Emotional Physical Social Spiritual Pain vs. Suffering at the End of Life Existential distress Dimensions of QOL Physical, psychological, social, spiritual Differs from person to person Defined by person Don t assume what quality means Requires interdisciplinary approach Pharmacological Therapies Nonopioids Acetaminophen NSAIDS Opioids Adjuvants Antidepressants Anticonvulsants Local anesthetics corticosteroids Nonopioids Acetaminophen Liver dysfunction NSAIDs GI toxicity Platelet aggregation inhibited Renal dysfunction Mechanism of action Opioids Codeine, oxycodone, morphine, hydrocodone, hydromorphone, oxymorphone, fentanyl, methadone Adverse effects Respiratory depression, constipation, sedation, urinary retention, nausea/vomiting, pruritus, Opioids not used in palliative care Demerol Stadol, Talwin 2
Nebulized & Sublingual Opioids Nebulized opioids provide no advantage over other routes of administration for dyspnea or pain Sublingual not faster onset, but convenience for pts who have swallowing difficulties Sublingual absorption of agents: Morphine 18% Fentanyl 51% Buprenmorphine 55% Methadone 34% Oxycodone 16% Antidepressants Adjuvants Tricyclic antidepressants, SNRI Anticonvulsants Neurontin, Lyrica Local anesthetics Lidocaine gel, EMLA & Lidoderm Corticosteroids dexamethasone Neuroablative Therapies Neurolytic blocks Neuroablative procedures Eisenberg, 1995; Furlan, 2001; Wong et al., 2004 Non-Pharmacologic Techniques Cognitive - behavioral therapies Relaxation Imagery Distraction Support groups Pastoral counseling Non-Pharmacologic Techniques (cont.) Physical measures (heat, cold, massage) Complementary therapies Ernst, 2004; Gillis, 2003; McCaffery & Pasero, 1999; Turk & Feldman, 1992 Ethical, Legal, and Social Issues in Pain Availability of opioids and disparities in access Increased scrutiny of prescribing practices related to controlled substances Reduced reimbursement for pain medications 3
Principles: Long Acting Medications Begin with immediate release forms as needed, once pain is controlled for 24-48hrs Calculate 24 hr dose & convert to sustained release medication. Sustained release formulations Morphine Oxycodone Transdermal fentanyl Principles: Long Acting Medications (cont.) Immediate-release for breakthrough pain Distinguish types of breakthrough pain Incident related Idiopathic End of dose failure Immediate-release breakthrough dose 10-20% of 24h oral dose 50-100% of IV or SQ hourly rate Principles: Use of Opioid Rotation Use when one opioid is ineffective even with adequate titration Use when adverse effects are unmanageable Principles of Equianalgesia Determine equal doses when changing drugs or routes of administration Reduce by 25% when changing drugs Use of morphine equivalents CASE STUDY A 45-year-old Portuguese female, Mrs. M, with a 3-year history of squamous cell cancer of the cervix presents with severe pain in the perineum. The patient lives at home with 6 children ranging in age from 5 to 18. She speaks little English. How might the nurse obtain a thorough pain assessment? What aspects of the pain assessment should be included? The patient describes her pain as an 8 on the 0-10 scale, occurring constantly in the perineum, but is worsened when she voids. She is currently taking Norco (5mg hydrocodone/325mg acetaminophen), 2 tablets every 4 hours (12 tablets - 60 mg hydrocodone 60 mg morphine). She frequently awakens and takes the medications during the night. She states (with help of the translator) that the medicines relieve the pain by approximately 25%. 4
What is your assessment regarding her pain? Is her pain controlled? What are your recommendations regarding her pain? Add more Norco since she is tolerating well? Keep Norco & add gabapentin 100mg tid po? Change to Fentanyl patch 100mcg/hr & use Norco for breakthrough pain? Change opioid to MS Contin 30mg every 12 hr po & add morphine liquid 10mg every 1-2 hrs po prn? Examination of the perineum reveals inflamed excoriated tissue from the labia to the rectum. Additionally, stool appears to extrude from the vagina. What members of interdisciplinary team would you consult? The excoriation is cleared, and the pain is under control with 10 mg of morphine q 4 hours (or 6 doses/day). She uses approximately 3 additional doses of 10 mg of morphine for breakthrough pain per day. Thus, she is using approximately 9 doses/24 hours. Unfortunately she awakens at night in pain. What might be the best analgesic regimen for this patient? She describes no adverse effects to the medications. The patient is being prepared for discharge to hospice at home when she expresses some concern regarding her son, who has a history of substance abuse. She is afraid he might use her medications. How would you approach this situation? Prior to her discharge to home hospice, the patient admits to the nurse that she is very afraid to die. When questioned further, she describes concerns regarding her children's care as well as her own guilt for having a child prior to marriage. What interdisciplinary team members would you involve in case? The patient is well cared for by her family at home. Her condition deteriorates and she becomes weaker, unable to swallow. Her home hospice team decides that IV morphine might be useful. Her current analgesic regimen is 100 mg long-acting morphine every 12 hours with 3 doses of 30 mg immediate-release morphine each day. 5
Key Nursing Roles What would be the appropriate IV dose? Total daily dose = 290 mg/24hrs. Change to IV 3:1 = 96.6mg IV/24hr. Divide 96.6mg by 24 hrs = 4.02 mg/hr.? Reduce by 25% =3 mg/hr Breakthrough dose 50-100% of hourly rate = 1.5-3mg/15min. Direct clinical care Patient/family teaching Education Identify system barriers Thank you Questions and Answers 6