Busting Opioids Myths.ppsx

mcmanalo@themedicalcity.com
Busting Palliative Care &
Opioid Myths:
Ensuring Equity in Access
for Cancer Patients
Dr. Maria Fidelis Manalo, MSc.
Palliative Care
Augusto P. Sarmiento Cancer Institute
The Medical City
Philippines

When someone
tells me that they
talked to a patient
about palliative
care and they
didn’t want it, I
always wonder
how it was
explained.

MYTH:
Having palliative care
means you will die
soon.
FACT:
Palliative care is not just
for the end of life. It is a
holistic approach that
includes caregiver
support, spiritual care,
bereavement and much
more.
https://www.chpca.ca/wp-content/uploads/2020/03/2020myths-sheet-enfinal.pdf

MYTH:
Supportive and
palliative care is just
for people with
cancer.
FACT:
All those who are
diagnosed with a
chronic life-limiting
illness can benefit
from palliative care.

MYTH:
Palliative care
manages pain
through the use of
addictive narcotics.
FACT:
Palliative care is holistic
care that provides
psychosocial and spiritual
care along with pain and
symptom management.

MYTH:
I can only get
palliative care in a
hospital.
FACT:
Palliative care services
are offered in many
places, including
hospitals, hospices, and in
your own home.

MYTH:
Palliative care is
generally just for old
people.
FACT:
Supportive and
palliative care is for
people of all ages.

MYTH:
Choosing palliative
care means that I'm
"giving up."
FACT:
When a cure is no longer
possible, supportive and
palliative care provides the type
of care most people say they
want at the end of life--comfort
and quality of life. The most
common statement made by
families who chose palliative
care for their loved one is, "we
wish we had known about
palliative care sooner."

MYTH:
My grandmother died in a
great deal of pain, but
that's just to be expected
as part of the dying
process.
FACT:
Supportive and palliative care
doctors, oncology and pain
nurses, and others are
specially trained to control
each person's pain, while still
keeping the patient awake and
alert whenever possible.

MYTH:
Everyone has access
to supportive and
palliative care.
FACT:
Though every person has the
right to supportive and
palliative care, there are many
around the world who does not
have access to supportive and
palliative care. In fact only
about 12% of the need for
palliative care is currently being
met worldwide.

MYTH:
If I choose supportive
and palliative care, I'll
have to give up my
own doctor(s).
FACT:
This is never true. Patients in
palliative care remain under the
care of their own physician or
physicians, who work with the
patient, family, and the
palliative care team to enhance
quality of life and ensure that
the patient is as comfortable as
possible, day in and day out.

MYTH:
I want to care for my
husband at home; I don't
want him to go to a
hospital or a hospice.
FACT:
Palliative care is not a place,
but a philosophy of care. The
majority of palliative care
takes place in the home,
where the person can be
surrounded by family and
familiar settings.

MYTH:
Palliative care just
keeps terminally-ill
people heavily
medicated; all they
focus on is the physical
process of a dying.
FACT:
Palliative care is highly specialized
and tailored to each individual, to
ensure the highest quality of life
possible to live each day until the
end. In addition, palliative care
utilizes complementary therapies
such as music and art, and provides
emotional and spiritual support to
the terminally-ill person and the
loved ones, including grief therapy
and bereavement support for the
family afterwards.

MYTH:
My son's doctor
suggested supportive
and palliative care; that
must mean that my son
has only a few days left
to live.
FACT:
Supportive and palliative
care is available to
anyone who has a life-
threatening or terminal
illness, regardless of
prognosis.

MYTH:
My partner is dying of AIDS,
and I want the most
compassionate care possible
for him. But someone told me
palliative care is only for older
people with cancer.
FACT:
Palliative care programs
have developed
guidelines to care for
anyone, at any age,
facing a life-threatening
or terminal illness.

MYTH:
My grandfather doesn't
have private insurance,
so he won't be able to
afford good end-of-life
care when he needs it.
FACT:
Palliative care physicians are
accredited by Philhealth. They
give senior citizen’s discount.
Since the focus of care has
shifted to comfort measures,
the palliative care physician
helps the family cut down
expenses arising from futile
diagnostics and therapeutics at
the end-of-life.

Definition of
Palliative Care
Palliative care is an approach to
patient/family/caregiver-centered health
care that focuses on optimal management
of distressing symptoms, while
incorporating psychosocial and spiritual
care according to patient/family/caregiver
needs, values, beliefs, and cultures.

TOTAL PAIN
CONTROL
Palliative care prevents and
relieves suffering through the
early identification, correct
assessment, and treatment of
pain and other problems,
whether physical, psychosocial
or spiritual. - WHO

Facts about
Cancer Pain

PAIN –
A feared and burdensome symptom
• Sources of pain:
– Due to cancer – local invasion
of tissues, obstruction
syndromes, metastases, etc
– Due to cancer treatment – post-
operative pain, phantom limb,
etc
– Pain related to cancer or
disability – bed sores, muscle
spasms, etc
– Pain due to other conditions –
arthritis, migraine, etc
• Up to 80% of advanced stage cancer patients suffer uncontrolled pain1
Types of Cancer Pain Prevalence
Head and Neck 67-91%
Prostate 56-94%
Uterine 30-90%
Genitourinary 58-90%
Breast 40-89%
Pancreatic 72-85%
Gastrointestinal 44-74%
Lung 44-67%
1. ACHEON Working Group, Kim YC, et al. Cancer Med 2015;4:1196-1204.
2. IASP - Epidemiology of Cancer Pain. Fact Sheet.
3. Scott-Warren J, Bhaskar A. Continuing Education in Anaesthesia Critical Care & Pain 2014;14(6):278–284

FACTS ABOUT CANCER PAIN
• 90 % of cancer pain can be satisfactorily controlled with current pain medications
• At least 25 % of cancer patients still die with unrelieved pain
1. Woodruff R, Palliative Medicine 4th ed., 2004
2. Bruera E., De Lima L., Wenk R., & Farr W., (eds), Palliative Care in the Developing World.,
3. International Association for Hospice and Palliative Care, 2004
4. Clearly J., J Palliative Medicine., 2007, 10 (6): 1369 – 1394.

Unrelieved Cancer Pain
Impairs Quality Of Life
• Loss of appetite
• Lack of sleep
• “Bad” mood
• Interference with relationships, Social isolation
• Depression, Anxiety
• Loss of energy and vitality
• Inability to perform daily activities
• Loss of income
• Challenge of existential beliefs
Watson M., Lucas C., Hoy A., & Wells J., Oxford Handbook of Palliative Care 2nd ed., 2009

Can We Start
Cancer Patients On ‘Strong’ Opioids?
WHO 3-step ladder (1986)

Eisenberg et al, 2005

A Validation Study Of The WHO Analgesic Ladder:
A Two-step Vs Three-step Strategy
Maltoni M. et al. Supportive Care Cancer, 2005 ; 13: 888-894.
Conventional Innovative
Approach Three-step strategy Two-step strategy
Pain Control
Transition from Step 1 to Step
2 does not improve analgesia,
and delays optimal pain
control
Patients receiving Step 3
(strong opioids) early had
significantly better pain relief
Satisfaction
Analgesia and patient
satisfaction with Step 1
analgesics alone and Step 2
analgesics is the same
Patients receiving Step 3 early
had greater satisfaction with
treatment

Current Recommendations
1. Marinageli F., Ciccozzi A., & Leonardis M., J Pain & Symptom Management, 2004 May; 27 (5): 409 – 416.
2. Maltoni M. et al, Supportive Care Cancer, 2005; 13: 888 – 894.
3. Mercadante S., Portio G, & Ferrera P., J Pain & Symptom Management, 2006 March; 31 (3): 242 - 247.
Moderate to severe cancer pain
Omit Step 2 of the WHO analgesic ladder and use Step 3
(strong opioids) for moderate to severe cancer pain
Strong opioids form the cornerstone in the
analgesic treatment of cancer pain

mcmanalo@themedicalcity.com F. Javier and M. Calimag, Opioid Use in the Philippines – 20 years after the introduction of the WHO analgesic ladder. Eur J Pain Supp 1 (2007) 19-22

An Official American Thoracic Society Statement: Update on the
Mechanisms, Assessment, and Management of Dyspnea

Opioids and Dyspnea
• Opioids have been the most widely studied agent in the
treatment of dyspnea.
• Opioids treat dyspnea through many mechanisms:
o Reducing respiratory drive
o Reducing anxiety
o Altering central responses to exertion
o Cough suppression
- American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease.
Chest 2010;
- Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline
from the American College of Physicians. Ann Intern Med 2008;
- Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea.
BMJ 2003.

Strong Opioids Available In The Philippines
Morphine Oxycodone Fentanyl Buprenorphine
Formulations
Oral (tablets)
Parenteral
Oral (tablets,
capsules, oral
solution)
Parenteral
Parenteral
Submucosal
Transdermal
Transdermal
Activity μ and κ μ and κ μ
μ partial agonist
κ antagonist
Bioavailability ≤40% 60-87%
SL - 54%
Transdermal – 92%
15%
Protein binding 30-35% 45% 80-85% 96%
Potency -
Twice as potent as
morphine
100x as potent as
morphine
75-115x as potent as
morphine
Use for opioid
naïve patients
Yes Yes Contraindicated* Yes
1. P&T Product Profiler Abstral®. February 2011
2. Riley J et al. Curr Med Res Opin 2008;24(1):175-192.
3. Levy MH et al. Eur J Pain 2001;5(Suppl. A):113-116.
4. Biancofiore G. Ther Clin Risk Manage 2006;2(3):229-234.
5. Curtis GB et al. Eur J Clin Pharmacol 1999;55(6):425-429.
6. Buprenorphine (TRANSTEC®) 35, 52.5 and 70 micrograms transdermal patch PH PI based on UK SmPC (v.16 Oct 2011). Revised 10 October 2017

FACT OR FICTION:
UNVEILING
OPIOID MYTHS

O p i o i d M y t h 1
Myth: Opioids are addicting.
Fact:
• There is a difference between physical dependence
and addiction.
• Physical dependence is a state in which physical
withdrawal symptoms occur when a medication is
stopped or decreased abruptly. This is expected.
• Addiction is a chronic disease in which people have a
poor control over drug use and continue to use the
drug despite physical and social harm.
• Addiction is rare for patients who are terminally ill
when the goal of care is comfort.
https://getpalliativecare.org/morphine-myths-reality/

O p i o i d M y t h
2Myth: If a person takes large doses of
opioids early in their disease process,
the opioids will not be as effective later
on when he/she needs higher doses.
FACT: There is no ceiling or maximum
dose for opioids. A patient should get
whatever dose is needed to provide pain
relief. One should not focus on “the
numbers” but instead be focused on
making sure the patient’s pain is
controlled.

MYTH: “I’ve heard that Morphine has
lots of side effects, and I feel bad
enough already.”
FACT: All opioids can cause nausea,
drowsiness and constipation. However,
all side effects will generally stop after
a few days, as your body adjusts, and
constipation can be easily treated.

MYTH: “ My doctor recommended
Morphine, but that was what my
father took just before he died – is
the doctor not telling me
something?”
FACT: Opiates are excellent drugs for
treating moderate to severe pain. If
you have an illness that is causing
acute or chronic pain that is not
adequately reduced by paracetamol
or ibuprofen, talk to your doctor
about using opiates. Morphine (and
other opiates) is NOT just for people
who are dying.

MYTH: Morphine is dangerous, because
it can make breathing slow down to a
dangerously low rate.
FACT:
• Morphine and other opioids are not
dangerous respiratory depressants
when used appropriately, for people
experiencing pain.
• Doses are increased gradually, and
the body quickly adjusts.
• Pain is a great stimulant to breathe!
• Sedation and drowsiness always
precede opioid induced respiratory
depression.
http://hpcconnection.ca/some-common-misconceptions-about-opioids/

Myth: Opioids cause a
person to feel foggy and lose
control.
FACT: When opioids are
taken on a regular basis,
tolerance quickly develops
and the feeling of being
foggy or out of control
should go away within a
week.

Myth: Opioids damage the body.
FACT: Opioids are very safe drugs
when used as directed. Of interest,
the American Geriatric Society has
determined that opioids are safer
for older people than non-
steroidal anti-inflammatory drugs
(NSAIDs) such as ibuprofen or
naproxen.

Myth: Not all types of pain respond
well to opioids.
FACT: Pain caused by nerve injury
(neuropathic) respond well to opioids.
Pain caused by bone injury may need
the help of additional medications
along with opioids to provide better
relief for these types of pain.

O p i o i d M y t h
9
Myth: Using opioids means that
you are a weak or bad person.
FACT: Because there have been
many stories in the news about
people who abused opioids,
their legitimate use for pain has
been questioned. As a result, too
many people suffer with pain
who could be relieved with
opioids.

O p i o i d M y t h 1 0
Myth: You cannot give
opioids to a child.
FACT: Children of all ages
can receive opioids at doses
appropriate for their weight
and age and with
adjustments based on
physical condition.

Each year, an estimated 40
million people are in need of
palliative care; 78% of them
people live in low- and middle-
income countries.
Adequate national
policies, program,
resources, and training on
palliative care among
health professionals are
urgently needed in order
to improve access.
The global need for palliative care
will continue to grow as a result of
the ageing of populations and the
rising burden of noncommunicable
diseases and some communicable
diseases.
Early delivery of palliative care
reduces unnecessary hospital
admissions and the use of health
services.
https://www.who.int/news-room/fact-sheets/detail/palliative-care

C a n y o u b e p a r t o f
t h e s o l u t i o n t o t h e
l a c k o f e q u i t y i n
a c c e s s t o
p a l l i a t i v e c a r e ?

Busting Opioids Myths.ppsx

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