Palliative Care in the Outpatient Setting: Pain Management Mustafa Ajam PGY1

Total pain concept Pain occurs in the context of a person’s life: -Fears and hopes for the future -spiritual beliefs -pressure and support from family -social and economic factors Their report of pain will be filtered and modified by these factors

Cancer pain is treated in 90% of cases Pain is common: -68% of end stage COPD patients report pain -64% of metastatic or end-stage cancer report pain Worsening pain = Worsening disease Cancer pain has different types Addiction is rare; tolerance is common

Pain assessment Asking and Believing Screen at-risk patients for pain using numeric 0-10 rating scale Screen nonverbal patients by asking caregivers or assessing behavioral signs of potential pain Assess pain’s impact on the patient’s functional status. Characterize the pain Appreciate non-physical causes

Barriers to pain management Physicians and patients barriers

Treating mild, moderate, or severe pain

Constant pain requires scheduled doses rather than PRN Bowel regimen and antiemetics for all Reassess after 24 hours to determine total required dose before you decide to switch to longer acting

Mr. R is a 34-year old man with metastatic melanoma Mr. R is a 34-year old man with metastatic melanoma. His pain has been controlled with 8 mg hydromorphone po q4h around the clock, but he wakes up at night in pain. You want to convert him to a long acting pain medication

30 / 7.5 = X Morphine PO / 48 X = 192 Decrease by 25% if pain was well controlled >> 132 Divide to BID >>> 72 >> ~60 BID Calculate breakthrough dose: 10%-20% of total daily dose >> ~ 15-30 mg q4h prn

Patient was getting 2 mg IV hydromorphone q4h in the hospital (controlled) and now you are planning to switch him to Oxycodone long acting as outpatient.

24 hr dose is 12 20 / 1.5 = X oxycodone / 12 X = 160 25% reduction since it is well controlled >> 120 mg >> 60 mg BID Breakthrough dose >> ~ 15 mg – 30 mg q4h prn

For fentanyl: A rule of thumb for converting from oral morphine to transdermal fentanyl is that the (microgram-per-hour) dose of transdermal fentanyl is equal to half of the (milligram-per-day) dose of oral morphine (i.e., 2 mg oral morphine/24 hours = 1 mcg/hr of transdermal fentanyl; 100 mg of oral morphine/day = 50 mcg/hr of transdermal fentanyl).

Appropriate oral starting doses Morphine: 5-10 mg (or even 2.5 mg in the elderly) Oxycodone: 5-10 mg Hydromorphone: 2 mg

Things to remember For long-acting oral opioids BID is better than TID Q4H for immediate release opioids (can add Q2H PRN for sever pain) Avoid morphine in renal failure. Fentanyl may be a better choice In hepatic failure, all opiates should be used with caution (i.e., start with lower doses than usual and avoid other sedating medications if possible).

If still in pain: -For moderate pain, increase by 25%-50% -For sever pain, increase by 50%-100% Never more than 100% in 24 hours One short acting and one Long acting

Immediate-release oral opioids will reach maximum effect within 1 hour Sustained release oral opioids will take many hours to reach maximum effect. Fentanyl patches may take 12-24 hours for maximal effect.

New onset mental status change Morphine is the cheapest

To avoid side effects Start low Use the same opioid for long-acting and short-acting breakthrough Rotate opioids Institute preventive measures Sedation from opioids is normally short-lived, but stimulants like methylphenidate can be helpful in some cases

Adjuvant analgesics and neuropathic pain Start low and titrate up; may take weeks to be effective Inflammation: NSAIDs or glucocorticoids Bone pain: Bisphosphonates, radiation, NSAIDs or glucocorticoids. Neuropathic pain include anticonvulsants (gabapentin and pregabalin) and antidepressants (tricyclic antidepressants, duloxetine, venlafaxine). Localized pain: Topical agents (NSAIDS, capsaicin, lidocaine, menthol)

Thank you