Webinar presented by VITAS Healthcare on August 10, 2017. Presented by Heather Veeder, MD

1. Palliation of Pain for Patients
Near the End of Life
James Wright, DO
Regional Medical Director
VITAS® Healthcare

2. Pain Management for Patients
Near the End of Life
Primary Reference:
Friedman TC, Kinzbrunner BM, Weinreb NJ, Clark M:
Management of Pain at the End of Life. Chapter 6 in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care:
A Practical Guide. New York: McGraw Hill, 2011, p. 125.

3. Goal
To effectively manage a patient’s pain using all available
tools, including pharmacological and non-pharmacological
interventions, based on the etiology or etiologies of the pain

4. Objectives
At the end of this presentation the participant should be
able to:
• Employ appropriate pharmacological interventions for pain
utilizing the WHO Analgesic Ladder as a guide
• Choose appropriate opioids for the treatment of severe pain
based on individual patient needs
• Articulate and follow the guidelines of effective pain
management when treating patients in pain
• Select and utilize appropriate adjuvant analgesics when
indicated
• Identify various non-pharmacological interventions for the
management of pain

5. Pharmacological Treatment of
Pain: WHO Analgesic Ladder
Source: McCaffrey,M. Pain: Assessment and Intervention in Clinical
Practice. November 17,1991
1
Step 2 - Moderate Pain (scale 4-6)
Opioids, Non-opioids & Adjuvants2
3
Step 3 - Severe Pain (scale 7-10)
Strong Opioids,
Non-opioids & Adjuvants
Step 1 - Mild Pain (scale 1-3)
Non-opioids & Adjuvants

6. Step 1 — Mild Pain (Pain Scale 1-3)
Non-opioids & Adjuvants
• Acetaminophen
– Tylenol
– Feveral
– Panadol
– Tempra
• Non-Steroidal Anti-
Inflammatory Drugs (NSAIDS)
– Salsalate (Disalcid)
– Ibuprofen (Motrin)
– Naproxen (Naprosyn)
– Indomethacin (Indocin)
– Cox-2 Inhibitors

7. Step 2 — Moderate Pain (Pain Scale 4-6)
Opioids, Non-opioids & Adjuvants
Combination Opioid/Non-opioid products
• Acetaminophen with codeine
– Tylenol with codeine
• Acetaminophen with oxycodone
– Percocet
• Acetaminophen with hydrocodone
– Lortab, Vicodin
• Ibuprofen and hydrocodone
– Vicoprofen
• Dose-limiting acetaminophen hepatotoxicity
– < 4 gms/day

8. Step 2 — Moderate Pain (Pain Scale 4-6)
Opioids, Non-opioids & Adjuvants (Cont.)
Tramadol
• Synthetic, centrally acting with opioid and non-opioid
properties
• Analgesic equivalent to codeine
• Immediate release limited to acute pain for less than
five days due to risk of seizures
• Extended release preparation for chronic pain
– 100, 200, 300 mg/day, max: 300 mg /day
• Avoid with creatinine clearance < 30 ml/min or severe
hepatic impairment

9. Step 3 — Severe Pain (Scale 7-10)
Strong Opioids, Non-opioids & Adjuvants
Commonly used opioid analgesic
• Morphine • Oxycodone
• Methadone • Hydromorphone (Dilaudid)
• Codeine • Fentanyl (Duragesic*)
• Hydrocodone • Levorphanol (LevoDromoran*)
Not recommended/not available in U.S.
• Meperidine (Demerol*)
• Heroin
• Buprenorphine

10. Equinalgesic Conversion Table
Analgesic Oral Morphine:Analgesic Ratio
Morphine 1:1
Oxycodone 1.5:1
Methadone Variable
Hydromorphone 4:1
Transdermal Fentanyl 50 mg/day:25mcg/hr
Levorphanol 7.5:1
Codeine 1:7
Hydrocodone 1:1
Meperidine 1:10

11. Morphine — Opioid of Choice
Multiple dosage forms
• Oral
– Liquid
– Short acting tablet
– Sustained release tablet (12 hrs)
– Sustained release capsule (24 hrs)
– Sprinkle (24 hrs)
• Suppository
• Parenteral

12. Morphine Therapy “PRN” vs. “ATC”
Morphine Therapy PRN (As Needed)
0 3 6 9 12 15 18 21 24
Time in Hours
TherapeuticLevel
MS-IR PRN
Morphine Therapy-Around the Clock
0
3
6
9
12
15
18
21
24
Time in Hours
TherapeuticLevel
MS-IR Q 4 H
MS-SR Q 12 H
MS-SR Q 24 H
Patient experiences:
• Pain prior to next dose
• Rises to toxic levels
Therapeutic levels remain
within therapeutic range
Patient avoids both pain
and toxicity between doses

13. Titration According to Pain
Severity
• If patient complains of mild pain:
– Increase baseline medication dose by about 10%
• If patient complains of moderate pain:
– Increase dosage 25-50%
• If patient complains of severe pain:
– Dose increase of as much as 100% may be required

14. Methadone: The Future Opioid
of Choice?
• Useful with patients on high-dose opioids and with mixed
nociceptive/neuropathic pain
• Useful in patients with renal insufficiency
• Highly cost-effective
• Long half-life, bi-phasic clearance
– Delayed toxicity
• Variable equianalgesic conversion ratios to morphine
– 4-5:1 (< 90 mg/day morphine)
– 8-10:1 (90-300 mg/day morphine)
– 12-20:1 (> 300 mg/day morphine)
• Multiple drug/drug interactions

15. Oxycodone
• Excellent opioid analgesic for moderate to severe pain
• Now available in multiple forms and strengths including
extended release
• No parenteral form available
• Recent concerns over street abuse potential
• Less cost-effective than morphine

16. Hydromorphone
• Widely available
• Used for severe pain
• Available in multiple dosage forms
– Used for subcutaneous infusion due to greater potency
• Onset 30 minutes
• Must be administered every three hours due to short half-life
• Sustained-release product released and recalled

17. Fentanyl Transdermal
(Duragesic®)
For use in management of severe pain for:
• Patients who have difficulty swallowing or are
unable to swallow
or
• Patients who exhibit poor compliance with oral
pain medication(s)

18. Fentanyl Transdermal
(Duragesic®) (Cont.)
Starting dose
• For opioid naïve patient:
– 25 μg/hr. Duragesic® patch
• For patients already on morphine or on another opioid:
– Convert current opioid dose to 24 hour morphine equivalent
– Convert patient’s 24 hour morphine dose using appropriate
conversion dose to fentanyl dose

19. Fentanyl Transdermal
(Duragesic®) (Cont.)
Special warnings
• Fever of 102º or higher increases skin permeability resulting in
an increase in plasma concentration by as much as 33%
• Other CNS depressant drugs create additive depressant
effects (reduce one or both agents by at least 50%)
• When discontinuing fentanyl it is important to remember that
this medication will continue to be effective for at least 24
hours after the patches are removed

20. Guidelines for Effective Pain
Management
Adjust route of administration to the patient’s needs
• Oral route is the preferred route if a patient can swallow
– Easy
– Safe
– Cost effective
– Generally convenient for patient and family
• 75%-90% of patients with pain can be controlled with oral
analgesics

21. Guidelines for Effective Pain
Management (Cont.)
Other routes of administration
• Transdermal
• Buccal/sublingual
– Actiq oralets
• 25% absorbed through buccal mucosa
• No dosing relationship to SR when used as BT
– Fentora buccal tablets
• 50% absorbed through buccal mucosa
• No dosing relationship to SR when used as BT
– High concentrate morphine liquid: not actually absorbed,
but trickles down esophagus into GI tract

22. Guidelines for Effective Pain
Management (Cont.)
Other routes of administration
• Rectal
– Very effective for patients approaching death who are
unable to swallow
– Opioid analgesics commercially available in rectal
suppositories
– Formulated rectal suppositories can be made with certain
analgesics by placing oral med in gelatin capsules
– Esthetically difficult route for some patients/families

23. Guidelines for Effective Pain
Management (Cont.)
Other routes of administration:
Systemic invasive routes:
• Subcutaneous or intravenous
– Repetitive
– Continuous
– Patient-controlled
• Intramuscular
– Contraindicated due to pain
Nervous system
invasive routes:
• Epidural
• Intrathecal
• Intraventricular

24. Guidelines for Effective Pain
Management (Cont.)
Administer analgesic on regular basis after initial titration
• Extended release or long-acting analgesics
– q 12 hours or q 24 hours
– Fentanyl patch q 3 days
• Goal is to prevent chronic pain
• Be sure appropriate immediate release analgesic for incident
or break-through medication is ordered

25. Guidelines for Effective Pain
Management (Cont.)
Use drug combinations to provide additive analgesia
and reduce side effects
• Opioid plus NSAID for bone pain
• Opioid plus neurontin for neuropathic pain
Avoid drug combinations that increase sedation
without enhancing analgesia
• Benzodiazepine tranquilizer plus sleeping pill

26. Adjuvant Medications
Neuropathic Pain
• Anti-depressents
• Anti-seizure medications
• Anti-arrhythmic medications
• Steroids
Depression
• Methylphenidate
• Amphetamines
Bone Pain
• NSAIDs
• Steroids
• Bisphosphonates
Muscle Spasm
• Baclofen
• Diazepam

27. Adjuvant Medications (Cont.)
Abdominal pain
• Sucralfate
• Antacids
• Anti-ulcer medications
• Anti-spasmodics
• Steroids
• Stool softeners and laxatives
• Foley catheter

28. Guidelines to Effective Pain
Management (Cont.)
Anticipate and treat side effects
Common adverse effects
• Constipation
• Nausea and vomiting
• Sedation
Uncommon adverse effects
• Respiratory depression
Correct use of opioids should not induce euphoria

29. Morphine and Respiratory
Depression
• Reduces respiratory rate, alveolar ventilation, response to
hypercapnea and hypoxia in normal human subjects.
• Chronic administration results in tolerance to respiratory
depressant effects
• Effective in relieving dyspnea in patients with advanced COPD
– Anxiolytic
– Preload reduction
– Reduces response to hypoxia in carotid body

30. Morphine and Respiratory
Depression (Cont.)
Bruera et al: Annals of Internal Medicine 1993
• 10 patients on chronic morphine for pain control
• Received a 50% increase in morphine dose as a bolus to
treat dyspnea
• Study in double-blind cross-over design with placebo for
comparison
• Results:
– Statistically significant improvement in subjective
dyspnea (p < 0.01)
– No change in O2 saturation or respiratory rate
Bruera E, et al: Subcutaneous morphine for dyspnea in
cancer patients. Ann Int Med 119:906, 1993

31. Morphine and Respiratory
Depression (Cont.)
Kinzbrunner and Tanis: ASCO Proceedings 2004
• 8680 terminally ill cancer patients admitted to hospice
• Pain level on admission directly correlated with survival
– LOS: no pain-39 (20) days; mild pain-38 (19) days;
– Moderate pain-34 (16) days; severe pain-29 (13) days

32. Morphine and Respiratory
Depression (Cont.)
Kinzbrunner and Tanis: ASCO Proceedings 2004
• Evaluation of survival based on pain reduction following 48
hours of treatment
– Severe pain to < 5: 35 (18) days vs. > 5: 27 (12) days
– All other sub-groups with no significant difference
– In no case was survival shorter in the group in which pain
was treated effectively
• Aggressive pain management on admission to a hospice
program shows no evidence of shortening life expectancy. It
may, at least for patients with severe pain, extend life for a
short but significant time period

33. Non-Pharmacologic Pain
Management
Physical medicine
• Range of motion
• Immobilization
• TENS
Neurosurgical & anesthesia
• Nerve blocks
• Surgical disruption of nerve roots, trunks or
spinal cord areas
Radiation therapy

34. Non-Pharmacologic Pain
Management (Cont.)
Behavioral mod
• Meditation
• Progressive muscle relaxation
• Music therapy
• Art therapy
• Guided imagery
• Massage therapy
• Therapeutic touch

35. Non-Pharmacologic Pain
Management (Cont.)
Psychosocial/spiritual support
• Active listening
• Reassurance
• Emotional support
• Education
• Counseling

36. For those eligible to obtain CE credit:
1. Enter the following website information in your web browser:
www.VIT.CmeCertificateOnline.com
2. Click on the following link:
Palliation of Pain – 12.8.16
3. You will be asked to complete a brief questionnaire, and your
certificate will be available to print immediately afterward. A
copy of the certificate will also be sent to you via email.
Questions? Email Certificate@AmedcoEmail.com