1. Supported in part by Arkansas Blue Cross and Blue Shield
and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT:
Event ID:

2. Opioids in Palliative Care
Masil George, MD
Associate Professor, UAMS Department of Geriatrics
Associate Professor, UAMS Division of Medical Humanities
Director, Geriatric Palliative Care Program, UAMS
Medical Director, Baptist Hospice
06/26/19

3. Objectives Define palliative care
Describe common conditions for which opioids are prescribed in palliative care
List ways in which opioids are used in palliative care

4. Join Poll everywhere
# to Text: Message: Masilgeorge681

6. What is palliative care?
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
(WHO:

7. Top 10 causes of Death Heart disease Cancer
Chronic Lower respiratory disease
Accidents
Stroke
Diabetes
Influenza and pneumonia
Kidney disease
Suicide

8. Dying in America
Nearly 75 percent of all deaths in the United States are attributed to just ten causes, with the top three of these accounting for over 50 percent of all deaths.
Studies have shown that approximately 80% of Americans would prefer to die at home, if possible.
Despite this, 60% of Americans die in acute care hospitals, 20% in nursing homes and only 20% at home.
 Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: The National Academies Press.

9. Palliative Care & Hospice

10. Length of Stay in Hospice
The typical patient spends 19.7 days in hospice care
35.3%: Fewer than seven days 27.0%: Eight to 29 days 17.2%: 30 to 89 days 8.7%: 90 to 179 days 11.8%: 180-plus days
Source: "NHPCO Facts and Figures: Hospice Care in America" National Hospice and Palliative Care Organization

11. The Hospice “Comfort Kit”
Morphine Liquid -used to treat Pain and Shortness of breath
Ativan (Lorazepam) — can be used to treat anxiety, nausea or insomnia
Atropine drops — used to treat wet respirations, also known as the death rattle
Levsin — an anticholinergic like atropine, also used to treat wet respirations
Haldol (Haloperidol) — can treat agitation and terminal restlessness
Compazine (prochlorperazine) — in either pill or rectal suppository form, this medication is used to treat nausea and Vomiting Phenergan (promethazine) — an anti-emetic like Compazine, Phenergan is used to treat nausea and vomiting
Dulcolax suppositories (Bisacodyl) — rectal suppositories to treat constipation
Senna — a plant-based laxative used to treat constipation
Fleet Enema — used to treat constipation if other treatments are ineffective

12. Common conditions that cause persistent pain
Mechanical or Compressive :
Low back pain, neck pain, musculoskeletal pain, visceral pain from expanding tumor mass
Musculoskeletal :
Myofascial pain syndrome
Neuropathic :
Peripheral (CRPS), HIV, sensory neuropathy, metabolic disorders, phantom limb, pain, post-herpetic neuralgia, diabetic neuropathy)
Central (poststroke pain, MS, Parkinsons disease, myelopathies, fibromyalgia)
Inflammatory :
Inflammatory arthropathies, infection, postoperative pain, tissue injury
Opioids for persistent pain in older adults Cleveland Clinic Journal of Medicine June;83(6): Castillo, MG

13. Considerations for drug of choice
Type and location of pain
Potential for adverse effects
Treatment of comorbidities (ex- depression, insomnia)
Drug interactions
Risk of misuse/ abuse
Cost
First, despite the fact that many
types of peripheral and central NP occur in clinical practice,
most RCTs have examined patients with either postherpetic
neuralgia (PHN) or painful diabetic peripheral
neuropathy (DPN). Second, there are few head-to-head
trials comparing different treatments and so direct comparisons
of efficacy and tolerability are generally not possible.
Indirect comparisons of different treatments are
problematic because RCTs differ substantially in research
design and outcomes reported. Outcome measures have also differed over time and across
studies, with more recent RCTs assessing treatment response
more comprehensively and including measures of
HRQoL and patient global assessments of improvement
and satisfaction, which were not collected in many older
trials. Finally, treatment duration in RCTs of medications
for NP has been relatively short, typically 3 months or
less, which is in marked contrast to the chronic nature of
most NP conditions and makes it impossible to extrapolate
the results to long-term use.
The choice of medication in an individual patient
with NP depends on a number of factors, including
the potential for adverse effects, treatment of comorbidities
(eg, depression, sleep disorders), drug interactions,
risks of misuse and abuse, and cost.
Reassess pain and health-related quality of life frequently
If substantial pain relief (eg, average pain reduced to ≤3/10) and tolerable adverse effects, continue treatment
If partial pain relief (eg, average pain remains ≥4/10) after an adequate trial, add one of the other 4 first-line medications
If no or inadequate pain relief (eg, <30% reduction) at target dosage after an adequate trial, switch to an alternative first-line medication

14. Communication
When offering pain treatment with strong opioids to a patient with advanced and progressive disease, ask them about concerns such as:
addiction
tolerance
side effects
fears that treatment implies the final stages of life

15. Provide verbal and written information
when and why strong opioids are used to treat pain
how effective they are likely to be
taking strong opioids for background and breakthrough pain, addressing:
how, when and how often to take strong opioids
how long pain relief should last
side effects and signs of toxicity
safe storage
follow-up and further prescribing
information on who to contact out of hours, particularly during initiation of treatment.

16. Opioids for chronic nonmalignant pain
Simplify the pain regime
Avoid polypharmacy
Start low, go slow, dose to effect
Source: AGS Panel on Persistent Pain in Older Persons. J Am Geriatr Soc Jun; 50(6 Suppl):S go slow, dose to effect

17. WHO Analgesic Ladder

18. Short Acting opioids Tramadol Codeine Hydrocodone Oxycodone Morphine
Oxymorphone
Tramadol is not recommended in patients who are taking serotonergic medications or in those with underlying seizure disorders.
Oral opioid medications are the most commonly prescribed medications in palliative care and geriatrics. Step 2 opiates of the WHO ladder Tramadol binds to opioid receptors and inhibits the reuptake of both norepinephrine and serotonin
generally consist of combination opiates containing hydrocodone, oxycodone with acetaminophen, or NSAIDs. These have ceiling limits based on the toxicity of the acetaminophen- or NSAID-dosing. Short-acting agents like oral morphine, hydromorphone, oxycodone, and codeine are used alone or in combination with acetaminophen, aspirin (ASA), or ibuprofen. Peak analgesic effect occurs within 60 minutes and the effect lasts for 2–4 hours in patients with normal renal function. These medications can be dosed at a 4-hour interval if given alone or 6-hour intervals if used in combination

19. Long Acting Opioids MS Contin Oxycontin Fentanyl Transdermal Patch
Methadone

20. Clinical Case # 1
Ms. Carter is a 72 y/o with chronic respiratory failure secondary to COPD and has conversational dyspnea. Chronic Medical problems include HTN, DM, anxiety, Chronic constipation, Hypothyroidism.
She has moved into her sister’s home and has a part time caregiver.
She is on Oxygen 24/7 at 3 lit. NC and uses a Bipap at night.
She complains of chronic back pain, panic episodes during the day when she feels like she is suffocating.
What is the etiology of her symptoms?
What medications may help?
What are common concerns when initiating these medications?

21. Clinical Case # 2
Mr. Werner is a 87y/o Nursing home resident with vascular dementia, and is on hospice. He is bed bound, needs total care, and is non verbal. Chronic Medical problems include HTN, CAD, CHF, DJD, CVA and CRPS.
He has a history of chronic pain and has stage IV pressure ulcers on his sacrum.
He grimaces frequently, and appears to be in pain. He is not swallowing his medications.
He is currently on Fentanyl 25 mcg q 72 hours, and oxycodone 10 mg every 4 hours/ PRN pain. He has not received PRN dose in the past 24 hours, and two doses in the past 3 days.
What could be the possible the etiology of his symptoms?
What medications may help?
What are common concerns with using medications?

22. Case Conference and Feedback
Continuing Education Credit: TEXT:
Event ID: