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

3. 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

4. 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

5. 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

6. Barriers to pain management
Physicians and patients barriers

8. Treating mild, moderate, or severe pain

10. 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

12. 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

13. 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 >> ~ mg q4h prn

14. 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.

15. 24 hr dose is 12
20 / = 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

16. 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).

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

18. 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).

19. 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

20. 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 hours for maximal effect.

21. New onset mental status change
Morphine is the cheapest

24. 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

25. 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)

27. Thank you