END-OF-LIFE CARE: Module 2

1. END-OF-LIFE CARE:Module 2 • Pain Management Module #2

2. Case of Mrs. Dolores Long Mrs. Dolores Long is a 70-year old widowed African American female who was recently diagnosed with lung carcinoma and metastasis to bone. She is being admitted to the hospital for a round of chemotherapy. A medical resident performs the admission H&P. Mrs. Long denies any symptoms. Physical examination is unremarkable. Mental status exam is significant for flat affect and poor eye contact. The resident finishes the exam and leaves the room. Mrs. Long’s daughter steps outside with the resident and explains that her mother has complained of severe pain and has become sedentary and withdrawn. She has refused the acetaminophen with codeine that was prescribed because she doesn’t want to “get hooked,” and the pills don’t help anyway. The resident is surprised, as Mrs. Long did not appear to be in pain. He explains that “nothing more can be done” for the pain, as strong narcotics like morphine might cause her to stop breathing and NSAIDs like ibuprofen could cause GI bleeding. However, psychiatry will be consulted to evaluate her depression. Module #2

3. Recognize and address barriers to effective EOL pain care Develop a better understanding of attitudes and beliefs about pain management Improve your knowledge and skills in assessing and treating pain Incorporate this content into your clinical teaching Learning Objectives Module #2

4. Background Barriers to treating pain Pain Assessment Non-pharmacologic treatment approaches Break Pharmacologic strategies Pain medications Application exercise Summary and goals Outline of Module Module #2

5. Pain in the Hospitalized Seriously Ill • 50% of conscious patients were in moderate to severe pain at least half the time in the three days prior to death • SUPPORT Study (1995), N = 9105 patients Module #2

6. Pain in Nursing Home Patients • 30% reported daily pain • 26% of these patients received no analgesia • Only 26% of them received strong opioids • What predicted inadequate pain management? • Advanced age: >85 years old • Poor cognitive function • Minority status • Bernabei (1998), N = 13,625 cancer patients Module #2

7. Pain in Outpatients • 67% outpatients with metastatic CA were in pain • 42% of those not given adequate analgesic therapy • What predicted inadequate pain management? • Discrepancy between patient and MD assessment of pain • Advanced age: >70 years old • Female • Better performance status • Minorities • Cleeland (1994), N = 1308 Module #2

8. Pain in 103 Children who Died of Cancer or its Complications • 89% died while suffering pain or other symptoms • Of those whose pain was treated, treatment was successful in only 27% • Wolfe, 2000 Module #2

9. Brainstorm • What makes pain so difficult to treat? Module #2

10. Six Major Barriers to Adequate Pain Care • Myth: That addiction is a common result of treating pain with opioids • Regulatory and legal concerns • System barriers • Deficits in knowledge and education • Fear of side effects • Assessment challenges Module #2

11. Definitions • Addiction: Psychological dependence on a drug. Drug-seeking behavior despite adverse consequences • Physical Dependence: Development of physical withdrawal reaction upon discontinuation or antagonism of a drug • Tolerance: Need to increase amount of drug to obtain the same effect • Pseudoaddiction: Behavior suggestive of addiction occurring as a result of undertreated pain Module #2

12. Barrier #1: The Myth of Addiction • Addiction differs from chemical dependence, tolerance, and pseudoaddiction • Increased use of opioid analgesics for pain does not appear to contribute to increases in opioid abuse (Joranson, 2000) • Fears are exaggerated due to referral bias • Pseudoaddiction complicates the picture • Increased opioid requirement is usually related to progression of disease, not tolerance Module #2

13. Barrier #2: Regulatory and Legal Concerns • Physicians are wary of prescribing controlled substances for fear of criminal and/or licensing sanctions • Risk is very low if indication and response are properly documented • Regulatory policies that control opioids get in the way • Triplicates • Renewal policies Module #2

14. #3 System Barriers • Lack of systemic use of practice guidelines • Pain management historically has not been incorporated into quality management structure • Many institutions still lack pain and/or palliative care services Module #2

15. Barrier #4: Deficits in Knowledge and Education • In patients, families, physicians, and other health care professionals • Pain management is still rarely addressed in medical school curricula • It is rarely included in textbooks • < 2% medical textbook content (Rabow, 2000) • < 5% nursing textbook pages (Ferrell, 1999) • Physicians lack awareness of their own knowledge deficits in pain management Module #2

16. Barrier #5: Bad Side Effects of Opioids - Key Points • Pain is a partial antagonist to respiratory depression and CNS sedation • Respiratory depression, sedation, and N&V relate more to changing blood serum levels of opioids than the steady state dose • Pain management and constipation relate to steady state dosing, not the rising blood opioid level • Treat prophylactically and continually Module #2

17. Barrier #6: Assessment Challenges • Health care professionals are more comfortable measuring objective data • We lack a scanner that is more accurate than patient report Module #2

18. Assessment of Pain:Key Dimensions • Mechanism • Neuropathic pain Abnormal state of central or peripheral nervous system gives rise to pain • Nociceptive pain Nerves responding appropriately to a painful stimulus • Timeline • Acute • Chronic Module #2

19. We are All ‘Color-blind’ to Chronic Pain Module #2

20. A Tool to Help Assess Pain • N - Number of pains? • O - Origin/causes? • P - Palliates, potentiates? • Q - Quality? • R - Radiation? • S - Severity, suffering? • T - Timing, trend? Module #2

21. Neuropathic Pain • Origin: • Nerve damage • Palliates/potentiates: • Set off by unusual stimuli, light touch, wind on skin, shaving (trigeminal neuralgia) • Quality: • Electric, burning, tingling, pins & needles, shooting (system isn’t working right) • Radiation: • Nerve-related pattern Module #2

22. Nociceptive Pain • Origin: • Tissue damage • Palliates/potentiates: • Worse with stress, pressure • Responds better to opioids, NSAIDs • Quality: • Sharp, dull, stabbing, pressure, ache, throbbing • Radiation: • Occasionally radiates (less well-defined), but not along an obvious nerve distribution Module #2

23. Visual Analog Scale • 1-3 Tolerable • 4-6 Change therapy soon • 7-10 Emergency SOS - change therapy now Module #2

24. Suffering • “A state of severe distress associated with events that threaten the intactness of the person” • Cassell,1982 • Subjective: No way to measure it • Significantly diminishes quality of life Module #2

25. Back to the Mnemonic • Timing: • When the pain occurs or with certain activities • Trend: • Whether a pain is getting better or worse over time Module #2

26. Total Pain • P - Physical pain • A - Affective distress • I - Interpersonal distress • N - Non-acceptance, or spiritual distress Module #2

27. Discussion • Strategies for alleviating pain: • Non-pharmacologic options Module #2

28. Behavioral therapy Spiritual counseling Physical therapy Psychotherapy Splinting Surgical correction Cold packs Meditation Support groups Radiation therapy Acupuncture Hypnosis Cultural healing rituals Heat packs Prayer Community resources And others… Non-pharmacologic Approaches to Pain Module #2

29. General Principles for Alleviating Pain • Assess with NOPQRST • Identify types(s) and location(s) of pain • Correct underlying cause, if possible • Consider special circumstances • Avoid specific toxicities • Look for ‘two-fers’ • Medication routes • Self-administered or by others Module #2

30. Pattern Matching Severity Time Module #2

31. How Would You Treat the Acute Pain Pattern? Severity Time Module #2

32. What Would a Chronic Pain Pattern Look Like? Severity Time Module #2

33. Basal pain medicine plus a different therapy for spikes: Predictable spikes - Short-acting agent prior to event Unpredictable spikes - Short-acting agent readily available Treating Chronic Pain Module #2

34. Chronic pain escalating at night - Why? Case Discussion Module #2

35. How might we treat Mrs. Long’s pain? Brainstorm Module #2

36. Neuropathic Pain Medications • Opioids, NSAIDs somewhat less effective • Classes of agents: • Tricyclic for dysesthetic pain • Anticonvulsants for shooting pain • Steroids to decrease peri-tumor edema • ‘Two-fers’ important in choice of agent(s) • Generally harder to treat than nociceptive pain • More likely to need specialist expertise Module #2

37. May be more effective than opioids with certain forms of pain Not necessarily less toxic than opioids Toxicity can be minimized For basal pain relief, consider longer-acting agent for ease of dosing NSAIDs Module #2

38. Combination Drugs • Advantages: • Aspirin or acetaminophen may act as co-analgesic • Lower level regulatory control • Disadvantages: • Available in short-acting formulations only • ‘Combo wall’ Module #2

39. Advantages: Low regulatory control Inexpensive Widely available Disadvantages: 10% cannot convert codeine to morphine Many drugs interfere with conversion Acetaminophen With Codeine Module #2

40. Acetaminophen with Oxycodone, Hydrocodone • Oxycodone combination contains 325 mg acetaminophen • Hydrocodone combination contains 500 mg acetaminophen • No clear advantage between the two • Dose equivalence is poorly established for hydrocodone Module #2

41. Case Discussion • Why didn’t Mrs. Long respond to acetaminophen with codeine? Module #2

42. Opioids • Morphine • Oxycodone • Hydromorphone • Transdermal fentanyl Module #2

43. Principles of Opioid Use • No ceiling effect • Dose to pain relief without side effects • Give orally when possible • Sub-cutaneous administration is basically equivalent to intravenous (and preferable) • Treat constipation prophylactically Module #2

44. Morphine • Advantages: • Inexpensive • Routes: PO, PR, IV, SC, lingual • Disadvantages: • Histamine release • Side effects, toxicity in high dose/renal failure • ‘Psychological allergy’ • Formulation:Long-acting ‘wax matrix,’ short-acting liquid, tab Module #2

45. For opioid-naïve, 5-10 mg PO q4 PRN After getting an idea of the 24-hour dose, go to long-acting Or start with 15 mg q12 long-acting There is no ceiling effect Standard Starting Dose Module #2

46. Oxycodone • Advantages: • Good alternative to morphine • Available PO: long-acting (q8-12) or short-acting • ? Less CNS alteration than with morphine • ? Less histamine release • Disadvantages: • More expensive than morphine • No parenteral form available in the U.S.A. Module #2

47. Hydromorphone • Advantages: • Available PO, IV, SC • Good alternative to morphine for parenteral use • No known toxic metabolites • Long-acting oral form now available Module #2

48. Transdermal Fentanyl • Advantages • Non-enteral administration • Change q72h • Steady blood levels • Disadvantages • Local skin problems • Delayed onset and offset • Cumbersome to titrate (only q72h) • 20% of people need it changed q48h • Expensive Module #2

49. What were the general principles of opioid use we mentioned earlier? Question Module #2

50. Case Discussion • What do you suggest to help alleviate Mrs. Long’s pain? • What more do we need to know? Module #2