Outline• Definitions• Case study “elizabeth”• Chronic vs. palliative symptoms• Pain• Other symptoms• Case study “John”• Case study “LM”(maybe if time)• Pump discussion and programming• Questions and conclusion

Chronic pain and palliative patients (1)

• Patient not terminal• Possible addiction

potential• Equal tolerance issue• Multiple adjuvants• Usually PO meds

• Patient terminal

• No addiction potential

• Equal tolerance issue

• Fewer adjuvants used

• PO then SC meds

Chronic pain and palliative patients (2)

• Assessment issues

• Physician issues• Social issues• Similar se issues

• Team assessment• Different dr.

issues• Different social

issues• Similar se issues

Chronic pain

• A pain state which is persistent and in which the underlying cause of the pain cannot be removed or otherwise treated.

• Chronic pain may be associated with a long-term incurable or intractable medical condition or disease.

Acute pain• Also known as warning pain, this pain is the discomfort or

signal that alerts you something is wrong in your body.

• Pain results from any condition that stimulates the body's sensors, such as infections, injuries, hemorrhages, tumors, and metabolic and endocrine problems.

• Acute pain usually abates as the underlying problem is treated.

• Early management of acute pain may hasten the recovery of the causative problem and reduce the length of treatment, therefore reducing health care costs.

Palliative pain

• Palliative pain can be described as a mosaic combinations of pain.

• It can be from the cancer, related to therapy, related to the cancer or unrelated to any of the above (arthritis, headache etc.) This can be a mosaic of nociceptive and neurop

Tolerance

• Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.4

Addiction• Addiction is a primary, chronic, neurobiologic

disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations.

• It is characterized by behaviors that include one or more of the following:

• impaired control over drug use• compulsive use• continued use despite harm• craving

Dependence

• Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood levels of the drug, and/or administration of an antagonist.

Palliative early/late

• Early refers to a palliative patient that is still taking oral medications and is very aware of their surrounding.

• Late refers to a palliative patient that is on subcutaneous medications and not aware of things (these are MDM terms)

WHO analgesic ladder

Non-opioid analgesics

• Aspirin, Acetaminophen

• Nsaid (non-steroidal anti-inflammatory) Celebrex, Voltaren, Naprosyn, Motrin, Ansaid, Mobiflex, Feldene, Dolobid, Clinoril, Indocid, Orudis, Toradol, Ponstan, Ultradol, Relafen

Opioids vs. Nsaids 

 

Titratable

Opioids Nsaids

Yes No

Acute adverse effects Resp. depression, nausea, constipation

GI, renal, hepatic

Allergies Rare Common

Addiction risk Potential risk No risk

Drug interactions Few Many

Organ toxicity over long-term use

None reported GI, renal, hepatic

Narcotics

• Codeine• Morphine• Hydromorphone• Oxycodone• Methadone• Fentanyl• (meperidine, propoxyphene,leritine,

levodromoran, hydrocodone, pentazocine, butorphanol, nalbuphine)

Codeine

• Codeine is available in a variety of forms such as: tablets, liquid, long acting tablets and injection. It is also available in a combination with caffeine, ASA or acetaminophen (Tylenol #3)

Codeine (2)

• Doses in excess of 3-4g (9-12 tablets) would be maximum

• Metabolism to morphine• Starting doses po 15-30mg• Dose frequency q4-6h• PO:SC ratio 2:1• Difficult to calculate tylenol

equianalgesic doses

Morphine

• Morphine is available as: liquid, tablets, SR tablets, sr capsules,suppositories, injection.

• Non-typical forms: nose spray, topical ointment, wound gel, epidural, lozenge, inhalation

Morphine (2)

• Starting po dose 0.5-1mg• PO:SC ratio 2:1• Dose frequency q4-6H• Triplicate prescription needed*

Oxycodone

• Oxycodone is available commercially as: Ir tablets, Sr tablets and combination (Percocet)

• Non-typical forms: injection, and oral liquid

Oxycodone (2)

• Starting dose approx. 5mg po• PO:SC ratio 2:1• Dose frequency q6h• Triplicate prescription needed• About double the strength of

morpine

Hydromorphone

• Commercially available as: liquid, IR tablets, SR capsules, injection (2,10,20,50mg/ml), suppositories, and powder

• Non-typical forms: nose spray, inhalation, sublingual tablets

Hydromorphone (2)

• Starting dose 1mg po• PO:SC ratio 2:1• Dose frequency q4-6h• Triplicate prescription needed• Five times more potent than

morphine

Methadone

• Commercially available as tablets and liquid

• Non-typical forms: capsules, inhalation, suppositories, injection

Methadone (2)

• Starting dose ?????• PO:SC ratio 2:1 but…….• Dose frequency q????• Triplicate required by licensed

physicians………..• Potency 1-10X more than morpine• Special physicians and Pharmacies

should/must be involved• Discuss addiction use

Fentanyl

• Commercially available as patch and injection

• Non-typical form: nose spray, trans-mucosal device

Fentanyl (2)

• 100 times more potent than morphine SC

• Dose frequency q1h (pump or btp)• Triplicate required• Must use chart to calculate patch

dose

Dose conversion calculations

• Daily dose PO• Tylenol #3 (30mg) 12/day equals

how much Dilaudid (1:1 for now)• Morpine MS contin 30mg 4/day

equals how much Dilaudid

Dose conversion calculations (2)

• If PO Dilaudid 20mg/day, what is the SC dose?

• If Po Morpine 200mg/day, what is the SC dilaudid dose?

• If po morpine is 400mg/day, what is the right Duragisic?

Duragesic dose

• 45-1342 25• 135-224 50• 225-314 75• 315-404 100• 405-494 125• 495-584 150• 585-674 175• 675-764 200

765-854 225

855-944 250

945-1034 275

1035-1124 300

Adjuvant Analgesics

• Cesamet (Marinol)• Clodronate• Valproic acid, tegretol, Dilantin,

Neurontin, rivotril, Topamax, Lamactil

• Antidepressants (see later)• Corticosteroids (see later)

Nausea

• Depending on the source of the nausea various agents can be used.

• Vestibular• Obstuctive• Mind• Infection• Toxin

Nausea (2)

• Zofran• Metoclopramide• Dexamethasone• Haloperidol• Dimenhydrinate• Lorazepam• chlorpromazine

Nausea (3)

• Medications can be given orally, topically (scopolamine, etc), SC or rectally

• Combinations maybe needed

Dexamethasone

• PO at a dose 1-4 mg 1-2 times a day can be used ( or sc at same dose) for adjuvant pain as well as nausea control

Hydration

• Normal saline• Dextrose/saline (2/3-1/3) just

depending if carbohydrates can be tolerated 1-2 l/day to keep a line open

• Wydase (compounded) can be added if not absorbing well (or heat)

Confusion

• Haloperidol starting at doses SC of 0.5mg and increasing to 5mg if needed

• Zyprexa and risperidal• Sedation may need to be started

with midazolam 0.1-1mg q1h preferably by pump

Constipation

• Be aggressive• Start with senokot and colace bid if

needed• Milk of magnesia, Bisacodyl , Fleet

(oral, mineral oil, regular), citromag, lactulose

• Erythromycin, Naloxone, Zelnorm, etc.

Dyspnea, anorexia, cachexia, stomatitis, xerostomia, sedation, secretions, seizures

• Morphine• Megace, cesamet• Akabutus, Nilstat, Pink-lady, diflucan• Scopolamine• Phenobarb, midazolam, Dilantin sups

Depression

• Very NB for chronic pain and possibly for 1st stage palliative but never needed in 2nd stage

Infections

• Topical infections can be treated normally with good wound care

• Internal infections should only be treated orally, IV or IM attempts should be discouraged

Gemstar pump

• Program pump to give 3mg/hour atc and 1.5mg/hour for btp every 20 minutes

• Review: priming, batteries, programming, changing bag

CADD-PCA

• Program pump to deliver 1ml/hour with a 1ml bolus every hour

• Review: programming, changing batteries, changing bag, priming, special problems

Other pumps

• Microject (types)• Kangaroo• Outbound• Paragon• Insulin pump types• Medi-sys• Abbott Provider/Aim Plus

References