A logical method for oncological pain treatment

A logical method for hospitalbased pain treatment Bob Arnold MD Institute to Enhance Palliative Care Objectives • By the end of the session, participants should be able to: – Describe the various steps in determining opiate orders – Describe the principle of equianalgesia and perform the calculations Objectives • By the end of the session, participants should be able to: – Write initial PCA orders – Describe how to dose escalate in a patient with more severe pain – Describe the major side effects of opiates (if we have time!) Objectives • What do you want to learn? Addiction fear • Dependence • Tolerance • Addiction – Evidence for – Dealing with addiction in the hospital • Pseudo addiction Steps in Opiate dosing • Calculate the previous days oral morphine equivalent • Determine if the dose is adequate for the pain and dose adjust • Determine the opiate that will be used and dose adjust for cross tolerance • Determine the route the opiate will be given • Determine the dosing schedule • Determine breakthrough dose Case 1 • Mrs Jones is a 63 year woman with back pain due to ovariancancer. At home she has been taking percoset 1-2 every 4 hours (8 day)In the ER, She got 3 mg iv hydromorphine over 3 hours and on the floor her pain is a 8/10. WHAT OPIATE SHOULD YOU USE? Opiates • Opioids – All opioid analgesics produce pain relief via interaction with opioid receptors in the brain/spinal cord and perhaps via peripheral opioid receptors – The mu receptor is the dominant analgesic receptor, but other receptors play a role in analgesia for certain opioids – There is no dose ceiling for opioids, only for acetaminophen in combination products Opioids (cont) • Opioids are classified by their interaction with the opioid receptors – pure agonist (morphine, hydromorphone (Dilaudid ®) oxycodone, codeine, meperidine, fentanyl) – mixed agonist-antagonist (Stadol ®, Talwin ®, Nubain ®) – partial agonist (buprenorphine) – pure antagonist (naloxone, naltrexone) Case 1 • You admit a patient with cancer-related chest wall pain. She is on MS Contin 15 mg bid with 5 mg prn q 3 hr. Last week, she called up herPCP who gave her percoset 1-2 q 4 hrs (she took 10 day) as well as started her on Oxycontin 10 two times a day. What should you do? Calculate the previous days OME • Since all potent opioids produce analgesia by the same pharmacological mechanism, they will produce the same degree of analgesia if provided in equianalgesic doses. • Thus, there is little basis to say, ―morphine did not work, but hydromorphone did work‖. Such a statement generally means that nonequianalgesic doses were used. Equianalgesia • SEE PAIN CARD – EVERYTHING ON THE CARD IS EQUIPOTENT • 10 mg IV MS = 30 po MS • 10 mg IV MS = 1.5 mg IV Dilaudid • 30 mg po MS = 7.5 mg po Dilaudid® • 30 mg po MS = 30 mg po oxycodone ** Note: Conversions factors are only a rough guide to approximate the correct dose. Common Conversions PAUSE & Calculate Equianalgesic Problem • Calculate: What is the patient’s OME (15 mg MS Contin bid; 10 mg oxycontin bid; 10 percoset day and 6 MSIR (5 mg)) Determine the “new” OME dose • Determine if the dose is adequate for the pain – Assess pain using a 1-10 scale – Fudge factors • Activities of daily living • Adverse effect • Previous pain score Opioid Dose Escalation Always increase by a percentage of the present dose based upon patient’s pain rating and current assessment 50-100% increase 25-50% increase Moderate pain 4-6/10 Severe pain 7-10/10 25% increase Mild pain 1-3/10 Determine the opiate that will be used • • • • Based largely on side effect profile Meperidine Morphine and renal failure Cross tolerance fudge factor – If changing opiate decrease OME 30-50% – BACK TO OUR CASE Case 1 • You admit a patient with cancer-related chest wall pain. She is on MS Contin 15 mg bid with 5 mg prn q 3 hr. Last week, she called up her PCP who gave her percoset 1-2 q 4 hrs (she took 10 day) as well as started her on Oxycontin 10 two times a day. What do you estimate her OME will be? What opiate would you use Ultra short Short Long Determine route and dosing schedule Short Acting Opioids • Parenteral or Oral • Oral only – morphine – hydromorphone (Dilaudid ®) – meperidine (Demerol ®) – codeine – Oxycodone/Acetam or NSAID – Hydrocodone/Acetam or NSAID – Note: hydrocodone is only available as a combination product. Short Acting Opioids • Oral dosing: – onset in 20-30 min – peak effect in 60-90 minutes – duration of effect 2-4 hours – Start with this for opiate naive – Can be dose escalated or re-administered every 2-4 hours for poorly controlled pain as long as the daily Acetaminophen dose stays < 4 grams Be careful with tylanol • Current recommendations is less than 3 gm/day • Vicodan ES has 750 mg Parenteral Opioids • IV is the route of choice if access is available – There is no indication for IM opioids – All standard opioids can be given SQ, by either bolus dose or by continuous infusion • More potent due to lack of first pass effect – Dose adjustment controversial Parenteral Opioids • IV or SQ bolus doses have a shorter duration of action that oral doses; typically 1-3 hours • The peak effect from an IV bolus dose is 5-15 minutes – Fentanyl >Morphine Dosing options • PCA • Long acting in concert with Breakthrough dosages • Short acting ―around the clock‖ • PRN PCA • Theory – Patient controlled results in less opiate delivered with same pain relief – Allows for a constant level of opiate rather than peaks and valleys – ALL PCA’s ARE CONSTANT INFUSIONS PCA • Bolus – Morphine or Dilaudid – Q 15 minutes – Get a high drug level before start the pca – The amount it takes to control pain is more than the amount it takes to keep one out of pain PCA • Patient controlled dosing – Remember that 10mg of morphine =1.5 hydromorphine – Constant infusions – Time interval – Hour lockout – Relative contraindications Case 2 • You admit a 72 year old man with acute pancreatitis. His pain is 9/10. What should you do? (He can not take po) Converting to oral dose Case 3- A patient with chronic low back pain is admitted with an exacerbation and put on a PCA. Over the next 48 hours, the patient used an average of 6 mg hour morphine and this controlled her pain. • What is the patient’s OME? • Is the pain well controlled? Long act with BKT • Long acting opiates allows a constant opiate with fewer doses. • Long Acting - 2/3-3/4 of total daily dose • All provide 8-12 hours of analgesia • All provide onset of analgesia within 2 hours • All can be dose escalated every 24 hours Long Acting Opioids • Oral – MS Contin ® – Kadian ® – Avinza ® • Transdermal – Fentanyl Patch (Duragesic®) – Oramorph SR® – Oxycontin® – Opana (oxymorphine) – methadone Long act Morphine-oxycodone • No clear benefit of one product over another – MS Contin/Avinza/Kadian/Oramorph contain morphine – Oxycontin contains oxycodone (70/30) – No difference in toxicity; No difference in addiction potential • Oxycotin/Oramorph/MS Contin must be taken intact—they cannot be crushed; they do not fit down GI tubes. • Kadian/Avinza pellets can go down large bore feeding tubes Transdermal Fentanyl • Slow onset of action: 13-24 hours – Duration of action: 48-72 hours • Should only dose escalate q 3 days – Fentanyl stays in circulation for up to 24 hours after patch removal • Place on hairless, non-irradiated skin • No ceiling dose • Equianalgesic conversion formula Conversions from/to Transdermal Fentanyl (Duragesic®) – 24 hour total dose of oral morphine, divided by 2 = dose in micrograms of transdermal fentanyl – Iv/hr dose= dose in mcg of transdermal fentanyl; – Example: • MS Contin® 30 mg q 12 = 60 mg MS/24 hours • 60 divided by 2 = 30; rounded to one 25 ug Fentanyl Patch • SO IN OUR PATIENT WHAT FENTANYL DOSE WOULD YOU USE Breakthrough Pain • Patients on any long-acting med always need a second, short-acting med, available for breakthrough pain • something they can take at least every 4 hours, preferably less • Guideline, dose of breakthrough opioid should be: 10-20% of 24 hour dose of analgesics and made available q2 hours • FOR OUR PATIENT ABOVE WHAT BKT DOSE WOULD YOU USE Other dosing schedules • Short acting ―around the clock‖ • PRN Case examples • 50 year old woman who comes in with severe pain due to a metastatic compression fracture • At home she is on oxycontin 10 mg bid, a 25 mcg fentanyl patch and 9 oxycodone 10mg/day. • Her pain is a 8/10 • What would you do? Steps in Opiate dosing • Calculate the previous days oral morphine equivalent • Determine if the dose is adequate for the pain and dose adjust • Determine the opiate that will be used and dose adjust for cross tolerance • Determine the route the opiate will be given • Determine the dosing schedule • Determine breakthrough dose Case examples • You are admitting a 75 year old woman with increasing pain because of breast cancer with invasion into the pleural wall. She has been on oxycotin 30 mg bid and percoset 1-2 every 4 hours for two days (taking roughly 10 a day). Her pain is a 8/10. What should you do? Steps in Opiate dosing • Calculate the previous days oral morphine equivalent • Determine if the dose is adequate for the pain and dose adjust • Determine the opiate that will be used and dose adjust for cross tolerance • Determine the route the opiate will be given • Determine the dosing schedule • Determine breakthrough dose Case examples • You are asked to see a post-surgical patient due to ―pain.‖ She is a 63 year old man who has cervical cancer. She was admitted for a SBO and had a venting gastrostomy. Shee says that his pain control is fair as long as they give him his medicine. Case examples • In the last 24 hours she has gotten 50 mcg fentanyl patch, 8 percoset, 10mg iv morphine and 2 mg iv hydromorphine. Her pain is his chronic mid-abd pain, although there is also some postoperative pain. Steps in Opiate dosing • Calculate the previous days oral morphine equivalent • Determine if the dose is adequate for the pain and dose adjust • Determine the opiate that will be used and dose adjust for cross tolerance • Determine the route the opiate will be given • Determine the dosing schedule • Determine breakthrough dose Dosing opiates in the actively dying patients • You are asked to see a patient admitted from the ER who is actively dying and CMO. He was not on any opiates at home. He seems to be moaning and has a respiratory rate of 45. What should you do? – Bolusing every 15 minutes – Using a drip based on bolus amount Opioid Adverse Effects Common Constipation Dry mouth Nausea / vomiting Sedation Sweats Uncommon Bad dreams / hallucinations Dysphoria / delirium Myoclonus /seizures Pruritus / urticaria Respiratory depression Urinary retention Constipation • Common to all opioids • Opioid effects on CNS, spinal cord, myenteric plexus of gut • Easier to prevent than treat Constipation . . • Diet usually insufficient • Bulk forming agents not recommended • Stimulant laxative – senna, bisacodyl, glycerine, casanthranol, etc. • Combine with a stool softener – senna + docusate sodium . . Constipation • Prokinetic agent – metoclopramide, cisapride • Osmotic laxative – MOM, lactulose, sorbitol • Other measures Nausea / Vomiting . . . • Onset with start of opioids – tolerance develops within days • Prevent or treat with dopamine-blocking antiemetics – prochlorperazine 10 mg q 6h – haloperidol 1 mg 6h – metoclopramide 10 mg q 6h . . Nausea / Vomiting • Serotonergic agents also are effective • Alternative opioid if refractory Sedation . . • Onset with start of opioids – distinguish from exhaustion due to pain – tolerance develops within days • Complex in advanced disease . . Sedation • If persistent, alternative opioid or route of administration • Psychostimulants may be useful – methylphenidate 5 mg q am and q noon, titrate – Less common-Aricept/Modafinil Delirium . . . • Presentation – confusion, bad dreams, hallucinations – restlessness, agitation – myoclonic jerks, seizures – depressed level of consciousness • Disorder of attention – CAM . . Delirium • Rare, unless multiple factors contributing, if – opioid dosing guidelines followed – renal clearance normal • Treat – Rotate opiate – Look at other medicines – Haldol Respiratory Depression . . . • Opioid effects differ for patients treated for pain – pain is a potent stimulus to breathe – loss of consciousness precedes respiratory depression – pharmacological tolerance rapid Questions • Call Palliative care with questions – Magee -8510 – Winnie Teuteberg – Elizabeth Weinstein’s clinic-641-4530