Download Pain cases and cost of care

Focus on pain:
An introduction to pain
management
For Romford VTS trainees Nov 08
Dr Corinna Midgley Medical Director
Saint Francis Hospice
Pain
• A common problem
– In the cancer context about 3/4 will experience pain:
1/4 do not
– A potentially complex problem with 1/3 of those in
pain experiencing at least 3 different kinds of pain
whether through cancer, treatment, debility or
concurrent disorder
Ref: Twycross: Symptom management in advanced cancer 2nd ed 1997
Patients with non cancer diseases are as likely as
patients with cancer to suffer pain in the last year
of life (94 vs 96%)
• CVAs:
– In the last week of life 42% experienced pain
• Heart failure, COPD, cirrhosis:
– level of pain experienced 3 days pre death was the same
as that of cancer patients
Addington-Hall J et al. Stroke 26:2242-8
Skillbeck J et al. Pal Med 12 (1998) 245-54
• Motor Neurone Disease:
– 73% have pain due to stiffness, spasm or
immobility/skin pressure
Oliver D. Pal Med 1998; 12:113-115
• The elderly:
– 40-60% of elderly in institutions are in pain
Almost 1/2 of those dying of cancer are over 75 yrs old
Ferrel BA. Pain evaluation and management in the nursing home.Ann Int Med
1995; 123:6681-687
Lefebvre-Chapiro S et al. Evaluating Pain in the Elderly. EJPC, 2001; 8(5)
191-194
– Indicators of poor pain management (NEJM 1995) include
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being aged over 70
being female
having a dementia
not having cancer pain
And in the dying?
– Studies confirm that people are more likely to suffer
pain in the last week of their life
(77 vs 67%)
Regional Study for Care of the Dying
– even in a hospice population with generally
well controlled pain, pain resurges for a
proportion in their last 3 days of life
(26% in hospice IPU population)
EJPC 2000 7(3)
We do need to anticipate pain
• And assess, explore, and record in an effort
to objectify, approach and monitor a
subjective phenomenon
Constructing a management plan
•
The best way of treating pain is to
remove the cause.
• If cause is unremovable…we need to
manage the pain in a way that the patient
can manage
Pain can be complex, with physical,
emotional and spiritual dimensions
>> PAIN if
<< PAIN if
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•
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• Safe
• Controlled and in
control
• Able/allowed to talk
• On top of emotions
• Confident of care
• Confident team
Scared
Suffering
Suppressed
Depressed
Unconfident
Vulnerable
Not all treatments are drug treatments
but a methodical safe, effective
approach to medicating is crucial
A medicines plan for pain:
– The WHO analgesic step ladder approach to
pain
– By the clock
• regular pain needs regular analgesia
– By the mouth
• most people’s preferred route-as effective as s/c, if
absorbing
– By the ladder
• If it still hurts-step UP the ladder
An effective treatment plan: safe - but
effective
The WHO Analgesic
Step Ladder
If pain is unrelieved on lower
step, then progress up the ladder
Strong opioid +/- NSAID +/- adjuvant
STEP 3
Severe
pain
Weak opioid+/- NSAID +/- adjuvant
STEP 2
Paracetamol +/- NSAID +/- adjuvant
STEP 1
Mild-mod pain
Moderate pain
Aims to build confidence in:
• Pain management for people with
advancing life-limiting disease
• Knowledge about and skill in using a
syringe driver: suitable drugs
• conversion of drugs from oral
dosage to syringe driver, ‘either IV
or subcutaneous’.
Scenario
• A 38 year old woman with known
glioblastoma stage 4
• Recently underwent radiotherapy and is on
a reducing course of dexamethasone
• She comes to see you with headaches
– What do you want to know?
• She has tried paracetamol up to 4 x daily
– What do you want to know?
• It is of no help
– What do you do?
• She is given cocodamol 8/500 2 qds
– No help
• She is tried on codydramol 2 tabs qds
– No help
• She then is given dihydrocodeine 30-60mg qds
– No help
• She is tried on solpadol 2 tabs qds
– No help
• She then tries tylex 2 tabs qds
– No help
The commonest cause of poor pain control in
adults with advanced life-limiting illness is
reluctance to step up the analgesic pain
ladder to an opioid
• So…if someone needs an opioid what is the
best one to start with?
• Oramorph
– Cheap, safe if used safely, suits most people,
works well for most people
– The challenge is-how much does this lady
need?
QUIZ:
• What is the usual starting dose of oramorph?
– The norm is 10mg orally, but this dependent on previous exposure
to weak opioids. With no exposure to step 2’s and especially if
elderly/frail start at 5mg
• Will she definitely take it? If not-why not?
– Patients often fear starting morphine as much as doctors do-the end
is near, it will hasten death, it will make me a zombie, there will be
nothing left at the end
• Any thing you should routinely advise on, or even coprescribe?
– Yes
– warn re constipation. Supply a laxative to start if one missed BO
– Warn re nausea/vomiting - affects 1/3 of those starting morphine.
Note its transience-enough to cover week one, just in case, should
be enough
QUIZ ctd
• You give her some oramorph to supplement her regular
cocodamol 30/500 2 tabs qds.
– When do you plan to revisit symptom control? How?
• She has taken 10mg oramorph 4 x in the last 24 hours
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What next?
Was it helpful?
Any side effects?
Any toxicity symptoms?
• Now she is on MST 30mg bd. What just in case dose of
oramorph should she be on?
– Convention-safe and effective in practice-is that the immediate
release drug should be tried for breakthrough pain at a dose of
1/6th of the total daily dose of morphine
– In this case-oramorph 10mg o prn
Toxicity symptoms include
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Somnolence
Hallucinations
Confusion
Respiratory depression
Side effects include
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Nausea
Constipation
Dry mouth
transient sleepiness
QUIZ:
• Now she is on MST 300mg bd. What just in case dose of
oramorph should she be on?
– Convention-safe and effective in practice-is that the immediate
release drug should be tried for breakthrough pain at a dose of
1/6th of the total daily dose of morphine
– In this case-oramorph 100mg o prn
• How did she get from 30mg bd to 300mg bd?
– By constant review and reflection on
• effectiveness of prns in last 24 hours
• any emergent toxicity symptoms
• Seek help if you feel out of your depth
– and titration up if
• no emerging toxicity
• break through medicine is effective
• Issues for concern:
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Rapid escalation of pain (and opioid dose)
It is not clear whether the morphine is effective or not
There are symptoms/signs of toxicity
You as GPs and/or district nurses feel unsafe or in any way out of
your depth
• What to do if your patient deteriorates and can no longer
manage oral medication?
– A syringe driver is invaluable
– Diamorphine is our 1st drug of choice
– Add up total amount of oral morphine taken in the last 24 hoursand divide by 3 for 24 hour diamorphine dose
– In this case it will be diamorphine 200mg/24 hours s/c
QUIZ ctd
• You have a patient who is clearly dying. He is unable to
manage oral medicine but in fact was on no analgesia. He
is uncomfortable
• Where do you start?
– What about a SD with diamorphine 10-15mg/24 hours-a safe and
sensible start dose. Plus prn diamorphine 2.5mg if pain
• What if he had been comfortable?
– you don’t need to give analgesia unless discomfort breaks through.
But-just in case do ensure that prn injectable medication and
authorisation is in the house: diamorphine 2.5mg sc prn.
• What if he had been on 30mg MST bd?
– you need to make sure he continues on the equivalent:
MST 30mg bd = 60mg orally /24 hours
Diamorphine equivalent = 1/3 of 60mg =20mg/24 hours
Plus prn diamorphine 5mg s/c (1/6th daily dose)
Most pain will be fully
responsive to the WHO ladder
But what if it isn’t?
note ‘ +/- NSAIDS, +/- adjuvants’.
What about
a. Other analgesics e.g. NSAIDS
b.Adjuvants
c. Steroids
d.Non pharmaco-physical interventions
e. Other opioids
In the dying patient opioids can often seem the only
option for analgesia because of difficulty in
managing oral medicines
• Why might we use another opioid when oral
morphine and s/c diamorphine are so good?
• There is still pain-but there is also toxicity
• The patient has severe renal failure
• The patient was on different oral opioids and you
are carrying on in the same vein
Alternative oral opioids
1. OXYCODONE
• An excellent and easy oral alternative to morphine.
– Includes oral IR liquid and capsules (oxynorm); SR
capsules (oxycontin), (also inj oxycodone)
– Oxycodone o is twice as potent as morphine o
• oramorph 10mg 4 hrly = oxynorm 5mg 4 hrly
• MST 30mg bd = oxycontin 15mg bd
• Provides an alternative to morphine if the patient is in pain,
but toxic with morphine
• Pros: An equally good analgesic, which can suit when
morphine hasn’t.
• Cons: watch for drug errors. It is getting a street reputation,
and it is more expensive.
• Is available, as oxycodone inj, into a syringe driver
E.g.
• A 67year old man with locally advanced
rectal cancer is really troubled by aching in
his bottom.
• The pain dulls with MST, and oramorph is
very helpful-reducing it from 7/10 to 2/10,
but over the last few weeks he has had to
increase his MST from 30mg bd to 300mg
bd and since his last increase is feeling
muggy, dreaming vividly and has started to
twitch.
Switch to oxycodone highly successful
with better pain control and abolition of
dreaminess etc.
• MST 300mg bd orally
– = 600mg oral morphine/24 hours
– (prn dose = 1/6th daily dose, 100mg oramorph as needed)
• This is equivalent in potency to 300mg oxycodone
orally/24 hours (as it is about 2 x as strong)
– (prn dose = 1/6th daily dose, 50mg oxynorm as needed)
• Great!
• But if a syringe driver is needed later on-it’s complex.
– 300mg oxycodone orally/24 hours = 150mg oxycodone inj/24
hours (with 1/6th - 25mg – sc prn)
– This = 15 x 1ml ampoules in SD, plus a prn which = 2.5mls…..
Alternative oral opioids
2. METHADONE
• Complex to titrate, but ultimately this is a simple oral
alternative to morphine.
– In liquid and tablet form. Also available as injectable.
• Pros: An equally good analgesic, which can suit when
morphine hasn’t
• BUT
• Con: Despite being cheap and effective, difficult to titrate
as no fixed conversion. No idea what dose your patient
will emerge with.
• Usually conversion is done in the hospice, over 6-7 days.
But can be done at home.
• Is available, as methadone inj into a syringe driver.
E.g.
• A 76 year old woman with a painful chest wall
underlying fungating breast cancer.
• She is on oxycodone, gabapentin to 900mg tds,
amitriptyline 25mg nocte, clonazepam 1mg nocte,
diclofenac 50mg tds and paracetamol 1g qds.
• The pain is building again; oxynorm dulls it but
she has developed hallucinations and twitches.
She fell x 2 yesterday and is scared.
FENTANYL
A very fast acting strong opioid
– Key advantages:Is an alternative to morphine - it
works on different receptor sites.
• So that it can be used when the patient is toxic but in
pain with morphine
• Is available for use via a variety of non oral routes
• Is not reliant on renal excretion, so is the maintenance
drug of choice in patients with severe renal failure
– Key disadvantages:
• it does not sustain for long
• it is not available as an oral preparation as it is poorly
absorbed from the GI tract
FENTANYL PATCH
• Pros:
• Patch only needs renewal every 72 hours, so can feel
liberating to the patient
– (note 1/5th pts do need more frequent change)
• Less constipating than morphine
• Cons:
• Conversion from other opioids requires a table, and
what prn should be used? (usually oramorph, with
oxynorm the usual 2nd line)
FENTANYL PATCH
• DANGER DANGER ***!the preparation MOST
LIKELY TO LEAD TO TOXICITY***
• The patch makes the fentanyl lie in a depot under the
skin so nothing will change rapidly when a fentanyl
patch is adjusted..:
– Absorption continues for up to 24 hours after a patch is
removed
– When a patch dose is changed it can take a good 16 hours
to show increased effect.
• So it should not be used in patients with rapidly
changing analgesic needs
• Can often feel complex when on a dying patient
ALFENTANIL and FENTANYL
• The patch makes the preparation slow to build and
slow to leave the body.
• When NOT in this preparation, fentanyl normally is
rapidly absorbed, distributed and broken down.
• Thus its value in
• Incident Pain
-fentanyl lollies absorb rapidly and provide a boost of
pain relief for 15-20minutes
-alfentanil inj’s provide fast short lived relief
• A syringe driver
-alfentanil = our 2nd line subcutaneous driver drug
of choice
• 79 years, End stage renal failure.
• Dialysis abandoned.
• Hiccuping and sleepy, and in pain from
diabetic peripheral neuropathy. Unable to
manage oral meds.
• SD of diamorphine?
• Or… alfentanil.
• Diamorphine 10mg=alfentanil 1mg.
• 61 year old lady.
• Advanced rectal cancer, with colostomy.
• Switched from morphine because of ? vestibulitis, to
oxycodone orally, but tablets appearing in the stoma bag
with increased pain control. Dose: 150mg o bd.
• So… switched to sc oxycodone.
• As pain escalated volume rapidly unmanageable.
• Switched to alfentanil.
• Now on 180mg alfentanil/day. No toxicity and reasonable
pain control-but alfentanil not available any more.
• What to do?
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43 year old lady.
Advanced abdominal disease.
Increasing pain.
Was on a 50mcg fentanyl patch-but-now
needing up to 4 doses of extra analgesia a
day.
• Struggling to manage oral meds.
• What to do?
BUPRENORPHINE
• Includes transdermal patches
• Similar to fentanyl transdermal, but start at a
lower dose range, and the patches can be
cut-allowing tiny doses to be given.
• Same limiting probs of time needed to reach
an equilibrium, and what to do if rapidly
changing needs, and , at dying-to supplement
or substitute?
References
• The invaluable BNF-ALWAYS LOOK!
– Excellent palliative care section at the beginning
– Always look up drugs that you do not feel completely
familiar with
• Symptom Management in Advanced Cancer: Robert
Twycross ISBN 1857755103
• Your local hospice will have protocols/guidelines on
the analgesic step ladder and all of the opioids, and
some common symptoms.
If your patient is ever on a drug you do not understand please
do contact your palliative care team or local hospice to discuss.
You can ask for a copy of the protocol for that drug.
Pain in the dying phase
• Is usually simple to manage.
• Note the simplicity of the LCP guidance on
pain management
The terminal phase
• ‘… is not simply a continuation of all that
has gone before-there may be new causes of
suffering for both the dying person and the
relatives..’
Oxford textbook of Palliative Medicine 3rd ed Ch 18 The terminal phase
• ‘In the end all the kind care that had been
given along the way went out of the
window-because she died the way she
died...’
A patient’s husband after she had died- a quote recalled by Dr John Ellershaw,
LCP conference, 2005 and one inspiration for developing the LCP.
The cost of care
• The concept of a ‘just in case’ box
– The aim is to be prepared for common problems and avoid delays
in helpful care
• Cost for supplier?
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Prescription writing time
Authorisation writing time
Pharmacist time
Pick up time
Storage care
Careful and appropriate disposal
Financial cost of just in case drugs
– For pain: 10 x ampoules of x opioid - enough for
several prns and a days worth of a syringe driver…
variable
e.g.
• diamorphine: 10mg x 10 amps = £13.60
(for pt prev on MST 90mg bd + oramorph 30mg o prn)
30mg x 10amps = £16.20
(for pt prev on MST 270mg bd + oramorph 90mg o prn)
• oxycodone injectable: 10mg x 10 amps = £14.00
note volume of stat = 1ml
(this would ‘cover’ pt prev on 60mg oxycontin bd + oxynorm 20mg
prn)
• alfentanil:
problematic for stats as very short acting.
(for interest alfentanil 5mg-equiv to 50mg diamorphine costs £2.65 )
Costs continued
– For nausea:
5 x ampoules of e.g. cyclizine (50mg / amp) - enough for a
syringe driver for a day plus 2 prns …
= £3.50
5 x ampoules of levomepromazine (25mg/amp) - enough
for a syringe driver for at least one day plus probably 4
prns…
= £10.68
Costs continued
– For restlessness:
5 x ampoules of e.g. midazolam (10mg/amp) - enough for a
syringe driver for a day plus usually at least 3 stat doses …
= £3.95
(more complex restlessness already covered by levomepromazine)
– for breathlessness:
already covered by opioid plus benzodiazepine
– for retained secretions:
5 x ampoules of hyoscine hydrobromide (400mcg/amp) - enough
for syringe driver set up plus 1-2 stat doses
= £13.55
Average total cost of just in case meds:
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Diamorphine +
Cyclizine +
Levomepromazine +
Midazolam +
Hyoscine +
Water for injections = £46.60
Average cost of continuing with
supplying medicines without reflection
on their value and appropriateness for
the changing patient
• High.
Many thanks for coming.