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Aspects of Managing Severe Pain
- 1. Palliative Care Summer Institute Aspects of Managing Severe Pain
- 2. Palliative Care Summer Institute Opioid Rotation Opioid Neurotoxicity Opioid Equianalgesic Dosing Adjunct medications
- 3. Palliative Care Summer Institute Opioid Rotation Indications Poor analgesia despite increasing doses Adverse effects are intolerable, toxicity Need different route of administration Change in clinical status (drug abuse?,malabsorption) Financial/drug shortage considerations -Fine and Portenoy: “Best Practices for Opioid Rotation JPSM 9 2009
- 4. Palliative Care Summer Institute Opioid Rotation • 30% pts need new route (severe nausea, mucositis) • Controlled Pain: reduce dose for incomplete cross tolerance • Uncontrolled pain = use equianalgesic dose • Toxicity: Lower dose, treat side effects, use adjuvants • Prevent toxicity by: • Using opioids cautiously renal or hepatic dysfunction • Intestinal colic Rx: Decadron, Glycopyrrolate, Octreotide
- 5. Palliative Care Summer Institute Opioid Rotation Guidelines Calculate Equianalgesic Dose using table Severe pain = use equianalgesic dose Mod pain or other route-lower this 25-50% (incomplete cross tolerance) Double check calculations (measure twice, cut once) Methadone-non linear conversion Reassess frequently
- 6. Palliative Care Summer Institute Opioid Equianalgesic Dosing EQUIANALGESIC DOSES OF OPIOIDS Analgesic Oral/Rectal mg = IV/SQ mg Morphine 30 10 Hydromorphone 7.5 1.5 Oxycodone 20 --- Hydrocodone 30 --- Codeine 200 130 Fentanyl --- 0.1mg = 100mcg Methadone see ratios below 1/2 Oral=IV Dose
- 7. Palliative Care Summer Institute Opioid Rotation GuidelinesMETHADONE CONVERSION RATIOS Oral Morphine Daily Dose MS:ME Examples MSmg:MEmg 0-100 3:1 100:33 101-300 5:1 300:60 301-600 10:1 600:60 601-800 12:1 800:60 >1000 20:1 1200:60
- 8. Palliative Care Summer Institute Opioid Neurotoxicity-Dx & Assessment Occurs with escalating doses (3 Glucuronide metabolites): • Frequency of myoclonic jerks • Hyperalgesia (allodynia) • Delirium, hallucinations, seizures Common risk factors: • Dehydration, • Drugs: (haldol, phenothiazines) • Renal, hepatic dysfunction, Mg++, Na+
- 9. Palliative Care Summer Institute Opioid Neurotoxicity-Treatment Observation Opioid dose reduction Opioid rotation Adjuvants Benzodiazepines Hydration
- 10. Palliative Care Summer Institute Morphine : Fentanyl Morphine Oral mg Morphine IV mg Fentanyl IV mcg/hr 30 10 100* 720 240 2400 100 30 50mcg/hr patch**
- 11. Palliative Care Summer Institute IV Morphine : Fentanyl patch • 1st 6 hrs: bolus IV morphine • 2nd 6hrs MS infusion at ½ the equianalgesic dose (100mcg fentanyl=MS 5mg/hr) • >12 hrs start full conversion (10mg/hr)
- 12. Palliative Care Summer Institute Methadone NMDA receptor antagonist, mu opioid agonist Excellent in opioid tolerance, neuropathic pain Long half life High oral bioavailability No active metabolites Inexpensive Prolonged QT concerns, so: • Start low, go slow • Limit to <100mg/day
- 13. Palliative Care Summer Institute Ketamine NMDA receptor antagonist Anesthetic, sedative, powerful analgesic Spares opioids-decrease opioids 25% initially, 25-50% @6-12 hrs and as needed until equilibrium Benzodiazepine helps Psychomimetic side effects Consider adding@ 100mg/hr morphine 1000mcg/hr fentanyl Initiate 80 mcg/kg/hr IV/SQ Continuous infusion 80-600 mcg/kg/hr
- 14. Palliative Care Summer Institute Lidocaine Sodium channel blocker Good for neuropathic pain IV/SQ infusion: Bolus 1-2mg/kg, then 0.2-1mg/kg/hr Titrate to effect Decrease opioid dose 50% every 6-12 hrs thereafter May have twitching at high doses
- 15. Palliative Care Summer Institute Other Adjuncts Gabapentin Bisphonphonates Antidepressants Anticonvulsants Muscle relaxants Local anesthetics Cannabinoids Topical agents
- 16. Palliative Care Summer Institute Interventional Procedures Trigger point injections Nerve blocks Epidural and Intrathecal catheters EBUS celiac plexus blocks
- 17. Palliative Care Summer Institute Symptom Management Guides Tarascon Palliative Medicine Pocketbook Symptom Management Algorithms EPERC FAST FACTS Our Hospice Nurses Hoagland’s Hospice Pharmacists Angie, Bree, Meg, Shaun 360 733-5877