Pharmacological Management of Severe Pain. Donato G. Dumlao , MD, FACP Medical Director for Palliative Care, Providence Hospital Supportive Cancer Care Specialist, Southern Cancer Center. Excruciating p ain. “Worse than torture”. Torture instruments.
Donato G. Dumlao, MD, FACP
Medical Director for Palliative Care, Providence Hospital
Supportive Cancer Care Specialist, Southern Cancer Center
“Worse than torture”
88 y/o with dementia FAST 7-C who is a nursing home resident under hospice. Consult was made because of uncontrolled agitation despite being on lorazepam and haldol. When I arrived I heard the patient screaming from the end of the hallway. Inside the room was the wound care nurse standing in front of a scared, screaming patient who looked like somebody who saw evil. She had a 4 cm by 8 cm non-healing vascular ulcer on the dorsum of her left foot. Prior to dressing changes, she receives lorazepam +/- haldol. She is also on Lortab 5/500 mg q 4 hours prn for pain. She received 1 tablet the past 24 hours.
The 2 greatest obstacles to pain management are failure to recognize the importance of pain (40%) and a lack of systemic approach (38%)
Only a few healthcare professionals will ever experience and understand chronic excruciating pain
Barriers involving healthcare systems have been reduced since the standards of the JCAHO---Which asserts that pain management is a patient right
However, barriers, such as failure to adhere to standards and guidelines, still exist
Use in cancer pain
46 year old male with recurrent, progressive head and neck cancer with excruciating neoplasm related pain on the right ear, jaw, and mouth. Pain is between 8/10 to 10/10. Breakthrough pain is spontaneous. Never had relief for a year The local interventional pain physician placed him on Fentanyl 100 mcg 72 hours and oxymorphone 10 mg q 4 hours. He uses 6 to 8 doses of Subsys1600 mcg gives him relief for 3 to 4 hours. He uses 6 doses per day. He gets significant pain relief when he gets IV morphine in the oncology clinic. He is depressed, anxious, grouchy, and sleep deprived. Weight continues to drop despite a PEG. There are no curative or life prolonging treatments available for his cancer. PPS=40 %. He is hospice appropriate but wife is still in denial.
EORTC Clinical Groups. Lancet Oncology. September 2009
Only 20% of cases requires attention of a clinician with advanced pain management
52 y/o male with metastatic lung cancer. Severe back, bilateral hip, and chest wall pain due to multiple bone metastasis. Had palliative XRT. Morphine controlled release titrated to 400 mg TID. On Morphine IR 30 mg, 2 to 3 tabs q 2 hours prn for breakthrough. Pain was controlled until he had his first chemotherapy. Had nausea and vomiting that led to dehydration. He developed confusion, generalized pain and some myoclonus. Discussed case with Oncologist. Syndrome can be due to terminal phasebut………
Morphine was stopped. Had aggressive hydration therapy. Methadone 5 mg q 6 hours was given (20% of conversion) and Dilaudid 4 mg po q 2 hours prn for breakthrough. Mental status improved, pain was perfectly controlled, and myoclonus resolved. He completed his palliative chemotherapy and survived for 8 months with good quality of life. He signed up with hospice 2 months before he passed away due to progressive weakness and onset of terminal delirium.
Conversely Opioid Induced Hyperalgesia would be worsened by increasing opioid dose