pain management in the palliative care setting m. thomas beets md
TRANSCRIPT
Objectives:
• Recognize the importance of cultural differences when developing pain management approaches to patients and families
• Have more insight into the multimodality approach to pain management
• Identify symptoms occuring in palliative care patients in order to evaluate the various treatment options
• Understand ongoing research in pain management of the palliative patient
Three Steps
• Assess the cause of the pain (may be multiple causes)
• Treat each type of pain
• Reassess continuously, expecially if pain uncontrolled
Categories of Pain
• (P)Physical• (A)Emotional• (I)Social or interpersonal• (N)Spiritual or existential
Neuropathic Pain
• Shooting• Burning• Paresthesias-tingling• Stabbing• Scalding• Often follows sensory nerve distribution• May have allodynia (pain from light touch)
Opioids
• Respiratory depression not usually clinically significant
• Physical dependence is not addiction
• Tolerance verses disease progression
• Very wide effective dose range
• Are effective by mouth
• Rare to have euphoria in palliative patients
Step 3, Severe Pain
Morphine
Hydromorphone
Methadone
Fentanyl
Oxycodone
+ Nonopioid analgesics
+ Adjuvants
Step 2, Moderate Pain
Acet or ASA +
Codeine
Hydrocodone
Oxycodone
+ Adjuvants
Step 1, Mild Pain
Aspirin (ASA)
Acetaminophen (Acet)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
+ Adjuvants
WHO 3-Step LadderWORLD HEALTH ORGANIZATION
Equianalgesic Doses of Opioid AnalgesicsPO, SL Parenteral
100 Codeine 60
- Fentanyl 0.1
15 Hydrocodone -
4 Hydromorphone 1.5
150 Meperidine 50
10 Methadone 5
15 Morphine (MS Contin, Morphine, Kadian, Avinza, MSIR, Roxanol)
5
10 Oxycodone (Percodan, Percocet, Oxycontin, Oxyfast, OxyIR)
-
1mcg/hr Fentanyl = 2 mg morphine/24 hours
Education on Palliative and End of Life Care 2007
Equianalgesic Example
• 40 yr old male, Lung Ca & Bone mets, severe pain
Morphine EquivalentCurrent: MS Contin 400 mg TID =1200 mg/24 hrs
Duragesic 2 100 mcg patches = 400 mg/24 hrsRoxanol 20 mg/ml x 10 doses of 1ml = 200
mg/24 hrs
Morphine Equivalent Total (Oral) =1800 mg/24 hrs
Equianalgesic Dose, one-third for IV use =600 mg/24 hrs
IV/Subcut Morphine Rate, divide by 24 hrs =25 mg/hr
Principles
• Work with oral morphine equivalents• Give around the clock• Limited cross-tolerance• Opioid rotation• Begin with low dose• In elderly begin with ½ the usual dose• Titrate• Q 4 hr booster is 10% of 24 hr dose
Principles
• Avoid meperidine-metabolized to normeperidine with 15-20 hr ½ life
• Avoid pentazocine-inhibits analgesia of morphine
• Avoid IM• Treat constipation-softening agent and
stimulant, avoid bulking agents
Principles
• Severe liver disease-opioids and benzodiazepines will have delayed metabolism (avoid methadone and acetominophen)
Neuropathic Pain
• Tricyclic antidepressants• Anticonvulsants• Local anesthetics• Baclofen• Capsaicin
Visceral Pain
• Oxybutinin 5-10 mg po tid• Hyoscyamine 0.125mg 1-2 po or sl q 4 hrs prn• Transdermal scopolamine• Glycopyrrolate 0.2 mg IV, subcut q 4 hrs
Other Pearls
• Ketamine• Steroids• XRT• Most opioids are effectively absorbed from the
rectum• Transdermal, transmucosal, subcut, IV• Epidural or intrathecal analgesics• Ketorolac• Lorazepam
Bibliography
• EPEC (Education in Palliative and End-of-life Care), Education of all healthcare professionals on the essential clinical competencies in palliative care. www.epec.net
Storey P, Knight C, UNIPAC Three: Assessment and Treatment of Pain in the Terminally Ill. 2nd ed. New York:Mary Ann Liebert, 2003.
• WHO Ladder: Cancer Pain relief and Palliative Care. Technical Report Series 894. Geneva: World Health Organization; 1990.