Download Gregory Phelps

11/8/2011
Palliative Pain Treatment
Managing Pain and Symptoms in the Terminal Patient
Terminal Patient
Greg Phelps MD MPH ETSU Pain Seminar November 15th, 2011
Disclosures
• Regrettably :
• I do NOT receive any honorarium, buyouts or bribes from any pharmaceutical manufacturers or medical devices
• I am no one’s paid consultant
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• I am not being paid to plug expensive variations of old stand by drugs. • I AM an employee of LHCGroup the parent company of your local hospice.
• I AM fellowship trained (University of Louisville) and certified in Hospice and Palliative Medicine
The Newest Definition of
Palliative Care 6/2011
From the Center for the Advancement of Palliative Care
Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from symptoms, pain and the stress of serious illness‐
whatever the diagnosis
whatever the diagnosis. The goal is to improve quality of life for both the patient and family. Palliative care is provided by a team of doctors, nurses and other specialists who work with a patient’s other doctors to provide and extra layer of support. Palliative care is appropriate at any age and any stage of serious illness and can be provided together with curative treatment. 1
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What Does a Palliative Care Doctor Do?
Two Functions 1. Experts in relieving symptoms ‐ pain, nausea, fatigue, constipation 2. Experts in Communication with patients and f ili
families (Dx, Tx, Prognosis) (D T P
i)
Unit of Care of care is patient and family
• Work done as a team! • Palliative Care Team usually includes physician, chaplain, nurse and social worker Pallim: Woolen Cloak used by ancient Greeks
that doubled as a blanket at night‐
Palliare‐ (latin) meaning to cloak Hospice and Palliative Medicine: First Hospice: St. Christophers London England
First US Hospice Connecticut 1973
Medicare includes Hospice benefit 1982 Recognized by American Board of Medical S i l i 2006 (FM IM PM&R AN GS
Specialties 2006, (FM, IM, PM&R, AN, GS, Pediatrics, OB, EM, Neurology, Psychiatry‐ CAQ‐
Certificate of Additional Qualification) • First ABMS recognized exam 2008
• First Fellowships accredited 2009
• Can Grandfather in until 2012 •
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Palliative Pain Treatment
Is Like Getting
Married Curative vs. Palliative Models
Palliative
Curative
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Primary Goal is cure
Object of Treatment is the disease
Symptoms treated primarily as clues to diagnosis
Primary Value placed on measurable data such as labs and tests
This model tends to devalue data that is subjective, immeasurable or bj ti i
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unverifiable.
Therapy indicated if it eradicates disease or slows progression. Patient’s body differentiated from mind. Patient viewed as collection of parts so there is little need to get to know the whole person. Death is the ultimate failure •
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Primary Goal Relieving Suffering
Object of Treatment patient and family
Distressing Symptoms entities themselves
Subjective and measurable data valued
This model values patient experience as an illness
Therapy indicated if it controls
Therapy indicated if it controls symptoms for relieves suffering
Patient is viewed as complex being with physical emotional social and spiritual dimensions
Treatment Congruent with values and beliefs and concerns of patient and family
Enabling a patient to live fully and comfortably until he or she dies is a success
Unipac 1: Characteristics of Curative vs Palliative Care Models
Page 8. 2003 It Is Till
Death Do You Part
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FSMB Definition of Addiction
• Addiction is a neurobehavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and in characterized by compulsive use despite harm. y
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Addiction may also be referred to by terms such as drug dependence and psychological dependence. Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and should not be considered addiction Physical Dependence
• Physical Dependence on a controlled substance is a physiologic state of neuro adaptation which is characterized by the emergence of a withdrawal syndrome if drug
emergence of a withdrawal syndrome if drug use is stopped or decreased abruptly, or if an antagonist is administered. Physical dependence is an expected result of opioid use. Physical dependence, by itself does not equate with addiction. Common Non‐malignant Pain Limits
300 mg morphine *
40 mg methadone
240 mg Oxycontin
120 mg of Opana ER 200 mcg/h fentanyl
Four doses of short acting med per day max is 30 mg oxycodone (Tenncare limits monthly allotment to 1200 mg of oxycodone or hydrocodone) • * most sources consider over 200mg of morphine or 100mg of methadone as “high doses” •
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“Mind the Gap!
Physician/ Patient (Mis) Communication
We Don’t Know if We Don’t Ask
• Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs
Atul Gawande: Letting Go, What Should Medicine Do when It Can’t Save Your Life, The New Yorker Aug 2, 2010
CAPC Survey of Attitudes
For Patients with Serious Illness
800 patient’s surveyed
Released June 28th 2011
Available at CAPC.org
• Biggest concerns: Cost, Control, Communication, Choice, Cure? Physicians not providing all treatment options‐ 55%
Doctors not sharing information with each other‐55%
Doctors not choosing best option for seriously ill‐
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y 54%
Patient and family leave physician office not knowing what they are supposed to do when they get home‐51%
– Patient lacks control over treatment options‐ 51%
– Doctor doesn’t spend enough time talking and listening with patient and family 50% – “Advanced” Illness does a better job of portraying a terminal illness than does “serious” illness
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The Question!!
Patients with advanced/terminal cancer (avg life 4.4 months)
• “Have you and your doctor discussed any particular wishes you have about the care y
you would receive if you were dying?”
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• Centers included Yale, Mass General New Hampshire Medical Center. 332 patients overall
• Conversations ranged from a low at Yale of 16.2% to 61.5% at New Hampshire Metastatic Non‐Small Cell Lung Cancer 151 Patients
• Palliative Care sample had life expectancy closer to one year (control 9 months) • Patients in Palliative Care arm of study had less pain, less depression less anxiety.
‐ JS Temel, JA Greer, A Muzikansky. Early Palliative Care for Metastatic JS T
l JA G
A M ik k E l P lli ti C
f M t t ti
Non‐Small Cell Lung Cancer. NEJM Aug 19, 2010 733‐742
“Survival times may also have improved as patients were helped to avoid preventable hospitalizations and fruitless chemotherapy” (Diane Meier MD ) Palliative Care Improves Lives
• In a study of 4493 terminal Medicare patients with: CHF, Lung Ca, Pancreatic Ca, Colon Ca, Prostate Ca entering Hospice/Palliative Care was associated with average INCREASE in life
was associated with average INCREASE in life span of 29 days
SA Connor, B Pyenson, K Fitch et al. Comparing Hospice and Non‐hospice Patient Survival Among Patients Who Die Within a Three Year Window. Journal of Pain and Symptom Management Vol 33 March 2007 238‐246
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Recommendations in Cancer Therapy
from ASCO and NCCN
• Doctors and patients need to have more realistic expectations
• Target surveillance or imaging to situations where benefit is demonstrated. (not demonstrated in pancreas ovary or lung.)
• Limit second and third line chemotherapies to single agents. (Cochrane review shows only small advantage of combined therapies in first round treatment
therapies in first round treatment
• Limit chemotherapy to patients with good performance status except highly responsive diseases (ECOG 3 or less) • Replace routine use of white cell CSF’s with reduction in chemotherapy in metastatic solid tumors
• After three consecutive rounds of chemotherapy limit further chemotherapy to clinical trials • Better integrate palliative care into usual oncology care. Smith TJ, Hillner BE. Bending the Cost Curve in Cancer Care. NEJM May 26th 2011
Questions for Palliative Chemotherapy
Treatment
• What is my chance of cure?
• What is the chance that this chemotherapy will make my cancer shrink? Stay stable? Grow?
• If I cannot be cured, will I live longer with chemotherapy? How much longer?
• What are the main side effects of the chemotherapy?
• Will I feel better or worse?
• Are there other options, such as hospice or palliative care?
• How do other people make these decisions?
• Are there clinical trials available?
– What are the benefits?
– Am I eligible?
– What is needed to enroll?
The Role of Chemotherapy at the End of Life "When Is Enough, Enough?" Sarah Elizabeth Harrington, MD; Thomas J. Smith, MD, JAMA. 2008;299(22):2667‐2678.
End of Life Discussions
• 123 of 332 (37%) patients with terminal illness had end of life discussions
• “Have you and your doctor discussed any particular wishes you have about the care you would receive if you were dying?”
• These patients elected less aggressive care with fewer ICU admits 4.1% vs
12.4%, fewer ventilation episodes 1.6 vs 11%,
• More aggressive care was associated with poorer quality of life for the d
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patient and higher risk of major depressive disorder for bereaved care givers. (PTSD)
AA Wright, B Zhang A.Ray et al, Associations Between End of Life Discussions Patient Mental Health, Medical Care Near Death
And Caregiver Bereavement Adjustment. JAMA 1665‐1673. Oct 8, 2008
In another study 2 of 75 patients hospitalized with cancer were found to have Spoken with their oncologist about advanced directives
Smith TJ, Hillner BE. Bending the Cost Curve in Cancer Care. NEJM May 26th 2011. 7
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Prognosis: The Chance to Plan
• Medical Literature Dx. 37%, Tx. 33%, Px. 4%
• Unofficial Physician Norms: (The opportunity to look stupid)
– Don’t make a prognosis
• If you have a prognosis, keep it to yourself unless asked
If you have a prognosis keep it to yourself unless asked
– Don’t be specific,
– Don’t be extreme
– Be optimistic • Doctors Err 2‐5x duration to the optimistic side* Prognosis‐ lack of activity is death foretold
Christakis NA. Death Foretold: Prophecy and Prognosis in Medical Care; University of Chicago Press 1999
The Shaman’s Role‐Prognosis
Something Physicians Know Little and Like Less
• What’s wrong with me
• What can be done to change it
change it
• What is the likely outcome
Patients are Never Told or Told Well
• Small Cell Lung Cancer
– Thirty‐five patients reported learning more about their prognosis from other patients in the waiting room than from their health care professionals. Physicians did not always want to pronounce a "death sentence," and patients did not always want to hear it.
• High‐Dose Chemotherapy (With Stem Cell Transplant))
– Physicians prescribing high‐dose chemotherapy overestimated survival, especially for patients with poor prognosis who might most need to balance toxicity with outcomes.
– The optimistic patients had no better survival than those who were more realistic.
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Patients are Never Told or Told Well
• Terminally Ill With Cancer
– Even if patients requested survival estimates, physicians said that they provided them only 37% of the time. Physicians reported that they would provide no estimate, conscious overestimates, or conscious underestimates 63% of the time.
• Solid Tumors
– In Belgium, only 39% of oncologists reported ever reviewing prognosis with patients. Most of the interview was spent on active treatment, not alternatives.
– Nearly all patients could name their diagnosis, but only 23% knew their stage, which is critical to appropriate goal setting.
– Oncologists consistently overestimated prognosis by at least 30%. In our own study, physicians' estimate of survival could be divided by 3.5 for actual survival.
A Communication Oxymoron:
Doctor: Latin “to Teach” • 2 million dollar grant to Ohio Medical school to teach communication from patient dying of cancer who was told poorly. • 2 of 75 terminal patients had advanced directives conversation with oncologists. –
Smith, TJ, Hillner BE, Bending the Cost Curve in Cancer Care. NEJM May 26th 2011, 2060‐2064)
• Only 123 of 332 (37%) stage IV cancer patients told of prognosis
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AA Wright, B Zhang A.Ray et al, Associations Between End of Life Discussions Patient Mental Health, Medical Care Near Death And Caregiver Bereavement Adjustment. JAMA 1665‐1673. Oct 8, 2008 • Two months before death only one half of metastatic lung cancer patients had talked with their oncologist about hospice. –
Huskamp HA, Keating MI, Malin JL. Discussions With Physicians about Hospice among Patients with Metastatic Lung Cancer. Archives of Internal Medicine 2009: 169 954‐962 • April 2011‐ Admitting it is doing a poor job communicating dire prognosis, the American Society of Clinical Oncologists issues new guide on Advanced Cancer Care Planning Available at Cancer.net
Patient Misperceptions of Treatment
• Patients Don't Believe Information About Benefits and Risks of Treatment • Metastatic Lung Cancer
– One‐third of patients thought they were receiving therapy with curative intent despite being told prognosis and goals of care.
• Head and Neck Cancer
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– Thirty‐five percent of patients believed their palliative radiation was supposed to be curative.
• Phase 1: Overoptimistic
– If told that a treatment helps 20% of people like them, patients reported a 44% chance of it helping them personally.
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ASKING? Goals of Care Discussion
• Pre‐planning and semiotics
• Introductions • Purpose
• Tell me about the patient
Tell me about the patient
• What do you Understand about the diagnosis??
• WARNING SHOT • Explain diagnosis
• Await reaction • Keep the focus on the patient • Did you (your father)… ever talk/advance directives • What would they want (substituted judgment)
• AND/ DNAR • Summarize and record.
Success of a GOC is based on how much family and patient talk!
Advanced Directive and Cost
• One quarter of all Medicare spending in in the final year of life.
• In high‐spending regions, adjusted spending on patients with a treatment‐limiting advance directive was $33,933, whereas adjusted $
spending for patients without an advance directive was $39,518, a difference of $5,585. The team prospectively studied data for 3,302 Medicare beneficiaries who died between 1998 and 2007
Nicholas LH, Langa KM, Iwashyna J, Weir DR. Regional Variation in the association Between Advance Directives and End of Life Medicare Expenditures. JAMA Oct 5 2011 Vol. 306 #13 1447‐ 53
Mean direct costs per day for patients who died and who received palliative care consultation on hospital days 7, 10, and 15 compared with mean direct costs for usual care patients matched by propensity score
Morrison, R. S. et al. Arch Intern Med 2008;168:1783‐1790.
Copyright restrictions may apply.
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Activity and Performance as Prognosis
• Performance Status The single most important predictive factor in cancer is Performance Status (‘functional ability,’ ‘functional status’): a measure of how much a patient can do for themselves, their activity and energy level. Patients with solid tumors typically lose ~ 70% of their functional ability in the last 3 months of life The most common scales used to
the last 3 months of life. The most common scales used to measure functional ability are the Karnofsky Index (100 = normal; 0 = dead) and the ECOG scale (Eastern Cooperative Oncology Group), (0 = normal; 5 = dead). A median survival of 3 months roughly correlates with a Karnofsky score <40 or ECOG > 3. Newer prognostic scales have been developed to help provide prognostic information Karnofsky Score (1949)
Used in Assessment of Cancer Usually 50% or less
Eastern Co‐operative Oncology Group
ECOG (1982)
ECOG PERFORMANCE STATUS*
Grade ECOG 0. Fully active, able to carry on all pre‐disease performance without
restriction 1.
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Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house to
carry out work of a light or sedentary nature, e.g., light house
work, office work
Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours Capable of only limited self care, confined to bed or chair more than 50% of waking hours
Completely disabled. Cannot carry on any self care. Totally confined to bed or chair
Dead
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Mortality PPS Score
Six Month Mortality %
Survival in Days average
• PPS Score 10‐20%....96%
• PPS Scare 30‐40%....89%
• PPS Score 40‐50%...80%
Median 1 Median 2
PPS 10%.... 1.88 6 PPS 20% ….2.62 6 PPS 30% ….6.70 41
40% ……..10.30 41
50%.........13.90 41
Prognosis in Advanced Cancer
Fast Facts for Palliative Care • Malignant hypercalcemia: 8 weeks, except newly diagnosed breast cancer or myeloma (see Fast Fact #151) 50% mortality at 30 days
• Malignant pericardial effusion: 8 weeks (see Fast Fact #209) • Carcinomatous
C i
meningitis: 8‐12 weeks (see Fast Fact i i i 8 12
k (
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#135) • Multiple brain metastases: 1‐2 months without radiation; 3‐6 months with radiation. • Malignant ascites (see Fast Fact #176), malignant pleural effusion (#209), or malignant bowel obstruction: < 6 months. www.eperc.mcw.edu/fastFactff_13htm
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When to Refer‐ CHF • Poor response to optimal treatment with diuretics and vasodilators . • NYHA Class IV, (symptoms at rest). Ejection fraction under 20%
• Ejection fraction under 20% . • History of refractory arrhythmias, cardiac arrest and resuscitation. • Patients should not be candidates for re‐
vascularization, or transplant, LVAD or resynchronization therapy. When to Refer‐ ESRD
End‐stage Renal Disease
All of first three plus one from 4 1. Not seeking dialysis or transplant
2. Creatinine clearance <10 (15 with DM) 3. Elevated BUN/Creatinine (>8 or >6 with DM) 4. Cachexia, massive edema, confusion/obtunded, intractable nausea/vomiting, generalized pruritus, oliguria (400cc/d) intractable hyperkalemia (K>7 not responsive to medical treatment) uremic pericarditis, hepato‐ renal syndrome, intractable fluid overload. When to Refer‐COPD
• Prognosis in lung disease is difficult to predict but the lung disease should be severe and progressive as documented by:
• Homebound/chair‐bound/ oxygen dependent. Hypoxemia </+ 88% on room air
Hypoxemia </+ 88% on room air
• Increased hospitalizations (1)/ED (4) visits in last year.
• Prior mechanical ventilation with exacerbation.
• Cyanosis fingertips or lips
• FEV1 < 30%
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When to Refer‐COPD (cont.)
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Dyspnea /hypoxemia at rest on oxygen
Unintentional weight loss >10% last six months
Resting tachycardia (>100 bpm)
Decline in performance scores. Patients with BODE Score 7 or higher had 80% Risk of mortality in 52 months
www.copd.about.com/od/copdbasics/a/BODEIndex.htm
When to Refer‐ESLD
End Stage Liver Disease
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Not a Candidate for Transplant
Ascites refractory to medical management
Hepato‐renal syndrome
Oliguria
Recurrent variceal bleeding
Spontaneous bacterial peritonitis
INR > 1.5 (PT >5 seconds over control
Albumin < 2.5
Hepato‐cellular cancer
Modeling End Stage Liver Disease (MELD) Score available at www.mayoclinci.org/meld/mayomodel7.html
When to Refer‐Debility/Failure to Thrive
• Decline in performance score
• Weight loss (BMI<22) supported by decreasing albumin(<2.5) or cholesterol
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• Dependence on 2 or more of the following:
• Feeding, ambulation, continence, transfers, bathing, dressing, dysphagia leading to inadequate nutrition, recurrent aspiration, • Increasing ER visits/hospital stays, FAST score of at least 6, pressure ulcers>2, recurrent infections. 14
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FAST Criteria For Dementia
Functional Assessment Staging
FAST (Functional Assessment Staging) Scale Items: Stage #1: No difficulty, either subjectively or objectively
Stage #2: Complains of forgetting location of objects; subjective work difficulties
Stage #3: Decreased job functioning evident to coworkers; difficulty in traveling to new locations
Stage #4: Decreased ability to perform complex tasks (e.g., planning dinner for guests; handling finances)
Stage #5: Requires assistance in choosing proper clothing
FAST Criteria For Dementia (Cont.)
Functional Assessment Staging
FAST (Functional Assessment Staging) Scale Items: Stage #6: Decreased ability to dress, bathe, and toilet independently:
• Sub‐stage 6a: Difficulty putting clothing on properly
• Sub‐stage 6b: Unable to bath properly; may develop fear of bathing
• Sub‐stage 6c: Inability to handle mechanics of toileting (i.e., forgets to fl h d
flush, does not wipe properly)
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• Sub‐stage 6d: Urinary incontinence
• Sub‐stage 6e: Fecal incontinence
Stage #7: Loss of speech, locomotion, and consciousness: •
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Sub‐stage 7a: Ability to speak limited (1 to 5 words a day)
Sub‐stage 7b: All intelligible vocabulary lost
Sub‐stage 7c: Non‐ambulatory
Sub‐stage 7d: Unable to sit up independently
Sub‐stage 7e: Unable to smile
Dementia is hospice qualified 7A‐7C
Actively Dying Stages
Early • Bed bound
• Loss of interest and/or ability to drink/eat
• Cognitive changes: increasing time spend sleeping and/or d li i
delirium (see Fast Fact #1)
(
F t F t #1)
Middle
• Further decline in mental status to obtundation (slow to arouse with stimulation; only brief periods of wakefulness)
• Death rattle – pooled oral sections that are not cleared due to loss of swallowing reflex
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Actively Dying Late
• Coma
• Fever – usually from aspiration pneumonia
• Altered respiratory pattern – periods of apnea, hyperpnea, or irregular breathing
• Mottled extremities
Mottled extremities
Time Course
• The time to traverse the various stages can be less than 24 hours or as long as ~14 days. Patients who enter the trajectory who are nutritionally intact, with no infection (e.g. acute stroke), are apt to live longer than cachectic cancer patients
Fast Facts # 3
The Pain Circuit
Chronic pain is often irreversible, intractable, progressive and meaningless.
Chronic pain results in anatomic and physiologic changes in the patient’s neuroanatomy
Pain perception is modified, both amplified and diminished at multiple levels in this circuit
The Pendulum Swings Both Ways
“We have two public health crises going on at the same time: One is the under treatment of pain and the other is prescription drug abuse.” Dr Scott Fishman JAMA •
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1994‐ Agency for Heath Care Policy and Research disseminates guidelines for Cancer Pain then Non‐
chronic pain 1996
1997 Expert Panel of American Pain Academy of Pain Medicine, American Society of Anesthesiologists and American Pain Society promulgate guidelines for pain treatment .
2001 JCAHO establishes “Pain as the Fifth Vital Sign” campaign. 2001 B
2001 Bergman v Chin 1.5 million dollar judgment Chi 1 5 illi d ll j d
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against Dr. Chin for allowing patient to die in pain (10/10)
And then the pendulum swings back
New focus on overdose deaths, doctor shopping criminal penalties .
Average 390 “for cause” surrenders of DEA licensure annually And Then
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June 2011 IOM releases study on cost of pain and it’s under‐treatment
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Pain Definitions
Pain is a more terrible lord of mankind than even death itself." ‐ Physician and humanitarian Albert Schweitzer (1875‐1965)
• Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in such terms as damage. The perception of pain is influenced by physical, psychological social, cultural and hereditary factors. • Persistent Pain: that lasts greater than 3‐6 months.
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• Types of pain: – Nocioceptive‐
– Somatic “Sharp, stabbing, aching” localized – Visceral‐ poorly defined, dull, cramping poorly localized
– Neuropathic‐ numbing, tingly, burning shooting
Pain Definitions (Cont.)
Pain is a more terrible lord of mankind than even death itself." ‐ Physician and humanitarian Albert Schweitzer (1875‐1965)
• Assessment of pain: location, quality, severity, relieving and precipitating factors and duration are all helpful to recommend appropriate treatment. Total Suffering‐ the psychosocial, emotional experience of pain the psychosocial emotional experience of pain
• Total Suffering
and it’s effects. • Pain is best described by the person suffering it!!
40‐70% of pain patients suffer significant unnecessary pain
Morphine: The hospice workhorse
• Long acting 8‐24 hours. MS ER or MS Contin, Avinza, Kadian, Embeda (Do not crush or cut in half)
• Short Acting Pills: MS IR etc
Short Acting Pills: MS IR etc
• Liquid: Roxanol various strengths, 20 mg/ml most common • Can also be given rectally, IV or Sub Q 17
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Pain Meds‐ Three Rx’s
Long acting, short acting and bowel regimen
• Pain scale 0‐10: 0‐3 no change 4‐6 25 to 50% increase 7‐10 50‐100% increase
• Set scheduled Q 4 h if short acting. PRN’s q
q
much more frequent‐q 1 h : about 10‐15% of total daily dose or the q four h dose. • Tally all meds, scheduled and PRN and create new scheduled dose. • If patient is using four or more PRN doses consider increasing long acting meds. The Gold Standard and Conversions
Oral Morphine Equivalents (OME)
Morphine
Hydromorphone
Oral Med
30 mg
7.5
IV/Sub Q Med
10 mg
1.5
Hydrocodone </
</= oral morphine </
oral morphine </= oxycodone
oxycodone
Oral morphine daily dose is double fentanyl patch dose
IE: 50 mcg/h patch equals 100 mg daily oral morphine.
Oxymorphone is slightly more that twice the potency of morphine So 40 mg Opana = about 100 mg oral morphine Codeine is 1/6th as potent as morphine, i.e. 30 mg of
Codeine = 5 mg of morphine
ALWAYS REDUCE DOSE IN CONVERSION 50% FOR INCOMPLETE CROSS TOLERANCE
Scientists have identified 9 different forms of mu opioid receptors All conversion tables are, at best, rough equivalencies Adjusting the Dose
• Patients will rarely notice a dose change of less than 25% • Mild to moderate pain, pain level of 4‐6 increase dose 25‐50%
• Moderate to severe pain, pain level 7‐10 adjust dose 50‐
100%
• PRN Dose should be about 10‐15% of daily long acting dose.
• Use of more than 3 rescue/breakthrough doses should trigger possible increase in long acting medication.
• In the hospital tally up total doses both scheduled and prns and then factor in current pain level to come up with new dose
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An example
• Patient with pancreatic cancer comes to hospice from oncologist complaining of back pain that is 9/10. Current medications include: Duragesic patch 50mcg/h, Oxycontin
include: Duragesic
patch 50mcg/h Oxycontin
80 mg BID and Hydrocodone 10/325 Q 4 h prn and he has take all six allotted • What would the new dose be?
First derive the OME
Oral Morphine Equivalent
• Duragesic 50 mcg/h = 100 mg OME • Oxycontin 80 BID ~100 mg MSER BID =200 OME
• Hydrocodone 10mg x 6 ~ 60 mg OME H d
d
10
6 ~ 60
OME
• 100+200+60 = 360 OME But Wait There’s More
• Also calculate that pain level of 9/10 calls for 50‐
100% increase in pain meds. At 50% this would be 180 mg added to above 360 mg = 540 mg for long acting and 10‐15% for breakthrough rescue doses so rescue dose would be 50‐60 mg q 1 gq
hour PRN. • However, Morphine ER only comes in set doses such as 200mg or Morphine IR in 15 and 30 so the final doses would be ….
MS Contin 200 mg TID and MSIR 30 mg 2 Q 1 h prn
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Side Effects
• Addiction? Very rare
• Neuro‐excitatory effects including twitches, seizures and hyper‐algesia
• Quit breathing with COPD? very rare
• Sedation: usually mild, transient lasting 2
Sedation: usually mild, transient lasting 2‐3
3 day max
day max
• Nausea/GI upset treat with food/anti nauseants a few days
• Constipation!!! Opioids paralyze the bowel it takes stool softeners, fiber and stimulant laxatives to keep up
• Opioids (except methadone) are primarily excreted renally
A Few Facts on Methadone
• Most common drug to overdose on
• First used in “methadone clinics’ as only long‐
lasting opioid available in 1970
• Unique action on neuropathic NMDA pain
Unique action on neuropathic NMDA pain
• No consistent conversion factor
• Highly variable half life 12‐96 hours
• Watch Qtc interval if >500 ms taper or d/c
• Many drug interactions check www.atforum.com
A few More Methadone Facts
• Best drug for patients with opioid toxicity such as neuro‐
excitatory syndrome.
• Best opioid for patients with renal failure as excretion is largely hepatic with much of the dose excreted unchanged in stool with no active metabolites. • Only long acting opioid in liquid form (10mg/5ml)
Only long acting opioid in liquid form (10mg/5ml)
• Very well absorbed sublingually • Can be given sub Q (1/2 oral dose) but irritating to skin • Tricky because has both immediate pain effects and a longer term (about 5 days) saturation effect that limits dosage changes to this interval • Usual starting dose 5‐10 mg BID to TID x 5 days 20
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Methadone conversions
As morphine dose rises percent methadone falls
Fast Facts Version: • OME Oral Methadone
• <100 3:1
• 100‐300 5:1 100‐300
5:1
• 301‐600 10:1
• 601‐800 12:1
• 800‐1000 15‐1
• >1000 20:1 VA/ DoD Version
• OME Oral Methadone
• <200mg 10‐30%
• 200‐500 10‐20%
200‐500
10‐20%
• 500‐1000 5‐10%
• > 1000 5%
Fast Facts #75 PCA pumps
When The Patient Must Have IV or Sub Q
• Most common opioids are morphine or hydromorphone (Dilaudid) in concentrations up to 50 mg/ml (morphine) or 10 mg/ml hydromorphone,
• Skin can usually tolerate 3 ml/hour Sub Q Skin can usually tolerate 3 ml/hour Sub Q
• Calculate daily IV dose then divide by 24 hours for basal rate. • Bolus rate is usually ½ hourly rate q 8‐15 minutes with lockout of 3‐5 time hourly rate.
See Fast Facts # 92 and #28
Pump calculations
• 72 yo with widely metastatic lung cancer has been on MS Contin 100 TID for bone pain along with Roxanol 20mg/ml 0.5 ml (10 mg) q 1 h prn
pain and has take 10 dose in last 24 hours but no pills are n s allo ed and liq id dribbling
now pills are un‐swallowed and liquid dribbling out • Patient is moaning in pain, family is frantic. You are asked by your nurse for a PCA pump
• She arrives at 7 am to start the pump. • What is the basal rate and bolus?
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11/8/2011
Pain Pump Calculation
• Oral morphine: 100 mg MS Contin x3 = 300
• + 10 mg of Roxanol x 10 = 100
400 mg
• Next convert to IV 400 mg/3 = 133.33
• Next divide by 24 hours = 5.5 mg/h
• Round to 6 mg per hour basal rate and 3 mg bolus q 15 minute (1/2 hourly rate) • Note we have not reduced by 50% for incomplete cross tolerance because same drug • Also did not increase for likely 9/10 pain scale because uncertain how much opioids he’s gotten in last day. Pain Pump Calculation‐3
• Your nurse returns that evening at 7 pm. • Patient is better but still complains of pain of 8/10. Accessing pump memory she finds patient has gotten 14 boluses of 3 mg each
patient has gotten 14 boluses of 3 mg each
• What should she adjust the pump to?
Pain Pump adjustment
Basal rate 6 mg /h x12 h =72 mg/12 or 144/24
Boluses 14 of 3 mg each = 52 mg or 104/24 h
Pain is still 8/10 so increase 50‐100% 144 + 104= 248 then increase 50 = 372
372mg/24h = hourly rate 15.5 (call it 16 mg/hr) • New Bolus = ½ hourly rate or 8 mg q 15 minutes prn
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11/8/2011
Adjunctive Medications
(Most Helpful for Neuropathic Pain)
• Tri‐cyclic Antidepressants Avoid Amitriptyline, (NNT 1.3) First line for DPN
• Watch for anti‐cholinergic side effects, syncope and QTc, • Anti‐convulsants: A i
l
– Newer‐ gabapentin (NNT 4.3), pregablin (NNT 3.3) – Older‐ carbamazapine (NNT 3.1), valproic acid
– Evidence lacking‐ topiramate, lamotrigine
• SNRIs’ Duloxetine (NNT 5.1) Venlafaxine NNT 3.1 • SSRIs’ Limited evidence of efficacy Ketamine
• Dissociative anesthetic used more than 30 years now found to have use in sub‐anestheia doses in refractory pain syndromes esp. neuropathic pain.
• Related to phencyclidine (PCP) Interacts with drugs at CYP34A (anti‐fungals, macrolides, protease inhibitors etc) • Non‐competitive NMDA* receptor blocker
Non competitive NMDA* receptor blocker
• Can be given IV, IM, sub Q or PO
• In sub anesthetic doses can cause dissociative feelings, “spaced out”, anxiety, nausea. Hallucinations with higher doses. • Possible Contraindications: increased intracranial pressure, seizures, prior CVA, hypertension, CHF Fast Facts # 132 *NMDA: N‐methyl, D‐Aspartate
Ketamine ‐2
• Non‐competitive NMDA* receptor blocker
• NMDA receptors in the dorsal horn associated with central sensitization (wind up) with allodynia and potentiation of pain response
allodynia and potentiation of pain response. • NMDA Receptor activation implicated in the reduction of opioid analgesia and tolerance.
• While small studies hopeful, not enough information to fully recommend. Kerr C., Holahan T., Milch R., The Use of Ketamine in Severe Cases of Refractory Pain Syndromes
in the Palliative Care Setting: a Case Series. J of Pall Med. V14, # 9 2011
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11/8/2011
Low Dose Ketamine *
• Sub Q/IV test dose 0.08 mg/kg/hour with lorazepam, alprazolam for anxiety.
• IV Therapeutic dosing: 4mg/h increase by 4 g
q
g/
mg increments q 12 h. Max 25mg/hour • Oral Ketamine: start at 10‐25 mg TID. Max dose 50 mg Q 6. Oral dose= ½ SubQ dose. Pharmacies can compound. • Anesthetic doses, that we would not be using, 1‐2 mg/kg IV or 6‐13mg/kg IM When starting ketamine reduce other opioid dose 30‐50% Pharmaco‐Economics
Two weeks supply/rough equivalents
Source: local Knoxville pharmacy
Fentanyl patch 50 mcg/h $ 137
Opana ER 40 mg $ 420
Oxycontin 80 $ 485
Exalgo 12 mg $ 410
Morphine Ex Release 100 mg BID $ 112
Methadone 10mg BID $ 9 Ralph’s Pretty Good, Pretty Short Pharmacopeia*
After morphine Doctor Can Practice “Pretty Good”
Hospice Medicine with About Six More Medications •
•
•
•
•
•
Haldol
Senna S.
Ativan
Glycoprryolate
Glycoprryolate Dexamethasone
Dronabinol
* With apologies to Garrison Keillor
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11/8/2011
Haldol
Very effective for nausea as well as delirium and hiccups. Can be given PO, Sub Q, Sublingual, IM Maximum oral dose 100 mg/day (50 parenterally)
Doses 4‐8 hours Usual starting doses 1‐2 mg to 5 mg. In geriatric start at 0 5 mg
0.5 mg. Peak effect reached in minutes sub Q, 60minutes orally Not on the Beer’s list. Cautions: risk of EPS, Prolonged QT interval, Malignant Neuroleptic Syndrome. anti‐cholinergic side effects, hypo or hypertension Superior to lorazepam for agitation
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Principle source for this talk: Hospice and Palliative Care Formulary USA Second Ed. 2008 Palliative Drugs.com Alternative Anti‐Nauseants
•
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•
Metaclopamide (Reglan) 10 mg PO or SQ
Chlorpromazine (Thorazine) 12.5‐50 mg IM
Hyoscyamine (Levsin) 0.124 Q 4‐6 H
Ondansetron (Zofran) 8mg PO/SubQ BID‐TID Sources of Nausea and treatments
• Vestibular‐ meclizine (newer anti‐histamines do not cross blood brain barrier as well) • Mind: anticipatory nausea –benzodiazepines
• Infection/Inflammation‐ may respond to anti‐
cholinergics/antihistamines
g
• Dysmotility‐ 5HT‐4 (metoclopramide) bind receptors that that then release acetylcholine to increase motility (anti‐cholinergics antagonize this)
• Chemoreceptor Zone: Affected by toxins, chemotherapy and some medications such as opioids (CRZ) mediated via D2 receptor blockers (Haldol etc) and 5HT3 receptors 25
11/8/2011
Senna S • Stimulant laxative mandatory in patients on opioids. (Sennosides plus docusate) • Usual dose 2 pills h.s. Stimulant usually non‐cramping and takes 8 hours to work (“2 pills in PM for BM in the AM) Max dos 8 pills a day. 8.8 mg/5ml liquid • Comes OTC, stains stool and urine reddish brown
Comes OTC stains stool and urine reddish brown
• Alternatives: Miralax 17 grams “mush with no push” Bisacodyl 5mg 1‐2 tabs or suppository or mag Citrate
• SMOG enema: equal volumes of sorbitol, glycerine, milk of magnesia, mineral oil • Methyl‐naltrexate (Relistor) (opioid induced constipation
• 8‐12 mg Sub Q QOD $$$! Lorazepam
(Ativan) • Useful for agitation and sedation –drug of choice for seizures.
• Can be given SL, PO, Rectally, Sub‐Q, IM or IV lorazepam Intensol liquid 2mg/ml • Duration 6‐72 h • For severe agitation can give with Haldol at 2mg q 30 minutes to sedation or 24mg/day • Non‐hospice maximum is 10 mg/day
• Longer acting benzodiazapines on Beers list Glycoprryolate and other Anticholinergics and Anti‐secretories
• Used for secretions and “death rattle.”
• Robinul (glycopyrrolate) quaternary amine, does not cross blood brain barrier like tertiary amines atropine and scopolomine which can cause confusion • Can be given po/sub Q • Starting dose 0.2 mg to maximum of 1.2 mg /day • Onset 30‐40 minutes both PO and SubQ
• Give Q 6 h same dose PO or parental
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11/8/2011
Other Anticholinergics
• Atropine eye drops 1% 2‐4 drops given ORALLY given Q 4 h. (2,5 and 15 ml bottles)
• Transdermal Scopolamine patch 120 mcg/24 h helpful for nausea and (off label) drooling lasts
helpful for nausea and (off label) drooling lasts 72 h. ( More expensive) • Hyoscyamine (Levsin) 0.125‐0.250mg tablets/liquid q 4h Dexamethasone (Decadron)
• Used for swelling related pain (brain, GI and bone) Can be given PO Sub Q or IM.
• Improves appetite and well being.
• Usually used in final six weeks of life.
• Usual doses 4 mg am and lunch (causes insomnia if given later in the day)
the day)
• Maximum dose 24 mg/day • Minimal mineral‐corticoid activity/ high gluco‐corticoid activity makes it suitable for high dose anti‐inflammatory therapy
• 6‐12 x more potent than prednisone 2mg dexamethasone = 15‐25 mg prednisone • Cautions: PUD, DM, psychosis
Marinol and Cachexia Medications
None of Them Work Very Well!
• Dronabinol (Marinol): THC derivative anti cachexia and emetic 2.5 ‐10 BID lunch and dinner.
• Megestrol acetate: (Megace) begin 80‐160 mg Megestrol acetate: (Megace) begin 80 160 mg
doubling q two weeks to max of 800 mg. (pills or liquid 40 mg/ml) Studies show only 1‐2 pounds of fat gained. Dexamethasone equivalent in effect 27
11/8/2011
Good for What Ails You
• ABHR Gel‐ Ativan/Benadryl/Haldol/ Reglan
combination topical medication used for agitation or nausea. Apply 1 ml Q 4 h g
y g
• Magic Mouthwash: Varying mixtures • Common mix: 2 grams Tetracycline powder, 2 oz nystatin solution, 2 oz lidocaine, mixed in 6 oz benadryl liquid. Sig: 1 tsp swished and swallowed. other mixtures include Mylanta or Carafate. Medications to Give to Patients You Don’t Like
• Darvocet‐ majority of effect is the Tylenol (Recently withdrawn from US market ) • Codeine severe gi upset
• Meperidine‐ on Beer’s List • IM injections Sub Q less painful and faster
• Naloxone: In unlikely case of respiratory suppression do NOT give Naloxone: In unlikely case of respiratory suppression do NOT give
full amp of naloxone!
• Patient will wake up screaming! • Instead dilute 1 amp in10 cc saline and give in slow 1‐2 cc increments until patient rouses
• NSAIDs: 16,500 annual deaths • Mixed agonist/antagonists: buprenorphine/Subutex, nalbuphine/ Nubain, butorphanol/ Stadol . These can precipitate withdrawal to other opiates
Opioid Perils
Number Needed to Treat,(NNT) 2.6 Number needed to Harm (NNH) 8
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Most opioids processed by kidneys
Testosterone/hypogonadism
Opioid Induced Neurotoxicity
Respiratory depression/COPD very rare
Addiction‐ rare!! (but watch the family) GI‐ Constipation as long as opioids prescribed
Nausea usually transient several days
Sweating Sedation transient 2‐3 days
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11/8/2011
The Beer’s List
(No Happy Hour Here!) • 1991 Group of geriatricians under Mark Beers MD formulated a list of medications to be given to the elderly only with significant additional fore thought due to increased risk in the elderly. (Not a ban) • 1999 CMS incorporated Beers list into nursing home regulations (Haldol is not on Beer’s list)
• For a full listing of the Beer’s list search by this name Anti‐Cholinergics
worsen‐ constipation, dry mouth, delirium, voiding, sweating, glaucoma • Anti‐cholinesterases for Alzheimer’s (Aricept Rivastigmine, Galantamine are cancelled out by anti‐cholinergic drugs such as oxybutin, Detrol Bentyl atropine. Detrol, Bentyl
atropine
• Many drugs are anti‐cholinergic: psycho‐
tropics, antihistamines, Tri‐Cyclic Antidepressants (Amitriptyline worst)
QTc Interval
• Many drugs we use can increase QTc interval
• QTc interval greater than 500 msecs can predispose to Torsades DePointes
• Methadone • Haldol,
• TCA’s • Beta Blockers
• Amiodarone and other anti‐arrhythmics
• 5HT3s‐ Zofran
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11/8/2011
Pill Burden
• Many patients near the end of life struggle with taking MANY medications. Not only volume but sheer number can become a problem. • Similarly many hospice patients will lose weight that will remedy elevated blood pressure type 2 diabetes
will remedy elevated blood pressure, type 2 diabetes and cholesterol. In time BP or glucoses may bottom out
• Finally many of these medications are preventive for conditions that may arise years down the road. • To that end we will often reduce pill burden to only those medications related to comfort and care of the dying patient. Advanced Directives
2004 Health Care Decision Act
• Appointment of Health Care surrogate (substituted judgment)
• Living Will‐ lays out desires if patient unable to speak for themselves. (TN law lays out penalties for willful destruction of living will or violation of same ) ( y
p
)
g p y
• POST (Physician Order Scope of Treatment) form is legal physician order of what is to be done with patient including DNR. Must be signed by doctor • In the absence of living will allows physician to choose healthcare surrogate whom the physician believes will best represent the patient’s interests. • Usual order: Spouse, adult children, siblings etc but not set in stone
• All forms available on‐line at www. endoflifecaretn.org. They do not require lawyer or notary only two witness.
Advanced Directive and Cost
• One quarter of all Medicare spending in in the final year of life.
• In high‐spending regions, adjusted spending on patients with a treatment‐limiting advance directive was $33,933, whereas adjusted $
spending for patients without an advance directive was $39,518, a difference of $5,585. The team prospectively studied data for 3,302 Medicare beneficiaries who died between 1998 and 2007
Nicholas LH, Langa KM, Iwashyna J, Weir DR. Regional Variation in the association Between Advance Directives and End of Life Medicare Expenditures. JAMA Oct 5 2011 Vol. 306 #13 1447‐ 53
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11/8/2011
Palliative Sedation
When unconscious is better than suffering
• When Refractory Symptoms in a dying* patient will respond to nothing else.
• Ethical Rule of Double Effect
• Common diagnoses in the Netherlands:
– Delirium/agitation 57%,
– Dyspnea 23% pain – Pain 17% * life expectancy </= 2 weeks
Palliative Sedation: Nation‐wide Guideline Version 2.0. June 5, 2010 Oncoline
Prior to Initiating Sedation
• Ensure thorough discussion with patient and surrogates, physicians and staff. Document discussions and obtain informed consent and DNR.
• Make sure patient is not acting out of psychiatric reasons: consider chaplain and psychiatric evaluation
reasons: consider chaplain and psychiatric evaluation.
• Establish goal to be met before beginning (any family coming from afar etc
• Assure peaceful quiet setting
• Discuss what other care such as enteral feeding ventilation etc is to be discontinued or continued. Palliative Sedation
• Opioids are continued for pain but not the central part of sedation.
• Common agents‐ starting doses:
–
–
–
Midazolam
Mid
l (sc/iv) 5 mg bolus 1 mg/ h
( /i ) 5
b l 1
/h
Pentobarbital (iv) 200 mg bolus 1mg/kg/h
Propofal (iv) 20‐50 mg bolus (may repeat) then 5‐10 mg/h
Discontinue monitoring vitals/ EKG etc. Fast Facts: 106 and 107 31
11/8/2011
Resources
• Blogs: Pallimed Geripal
• Fast Facts www. eperc.mcw.edu/EPERC/FastFactsand
concepts
• American Academy of Hospice and Palliative Medicine‐
AAHPM org
AAHPM.org
• National Hospice and Palliative Care Organization ‐NHPCO.org
• Center for the Advancement of Palliative Care‐ CAPC.org
• Endoflifecaretn.org for POST and other forms
• Palliativedoctors.org (AAHPM’s website for patients)
• Hospice and Palliative Care Formulary USA (Palliativedrugs.com) Sometimes I Give Myself the Creeps
The End and Thank you
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