PAIN CONSIDERATIONS IN PALLIATIVE CARE

Transcription

1 PAIN CONSIDERATIONS IN PALLIATIVE CARE Eric Anderson, MD, Palliative Medicine United Hospital September 22, 2017 DISCLOSURE The presenter has no financial relationships to disclose. OBJECTIVES 1. Name two ways palliative care improves outcomes in serious illness. It controls symptoms to improve quality of life It aligns the medical care to the patient s goals and values. 2. Identify two psychosocial factors that influence pain levels Lack of sleep Worrying about personal or financial issues 3. What assessments are most helpful in evaluating the patient whose pain is poorly controlled? Pain pattern: relief and duration of relief Functional pain scale Topics we will cover 1. Serious illness and Palliative Care 2. Opiods: Refractory pain and Methadone 3. Challenges to controlling pain in palliative care patients 4. Assessing the patient whose pain is not improving 5. Constipation 6. Anorexia and cachexia: The dwindles PALLIATIVE CARE in 51 words Palliative care aims to reduce suffering and improve quality of life for patients with advanced illness, and their families. Center to Advance Palliative Care ( AllinaHealthSystems 1

2 Palliative care is provided by an interdisciplinary team and offered in conjunction with all other appropriate forms of medical treatment. A patient does not have to be terminal to receive palliative care. Center to Advance Palliative Care ( Physical Well Being Psychological Well Being What is patient centered care? Social Well Being Spiritual Well Being ELNEC End of life Nursing Education Consortium Physical Well Being Psychological Well Being What is person centered care? DEATH FROM SERIOUS ILLNESS Social Well Being Spiritual Well Being 3 or more admissions in the 2 years before death. We looked at the final admission. ELNEC End of life Nursing Education Consortium AllinaHealthSystems 2

3 Allina Hospital Study 1. Average age? 65? 75? 85? 1. What diagnoses did they have? 2. How many ED visits + admissions? 3? 7? 26? 3. How many MD s were writing orders? 3? 8? 19? Net Expense of the Last Admission: 29 patients $0 -$200 -$400 -$600 -$800 -$1,000 -$1,200 -$1,400 -$1,600 Lung Kidney COPD HF Total cost = $1 million *Cost data from Abbott Northwestern Hospital What would help this situation? Give optimal medical care, wherever the patient is. Reduce distressing symptoms. Hold meaningful conversations about advance directives Align care with the patient s goals and values. Support family caregivers Early palliative care for patients with metastatic non small-cell lung cancer The Spectrum of Palliative Care PAIN IN PALLIATIVE CARE AllinaHealthSystems 3

4 Symptoms commonly encountered in serious illness 1. Nociceptive pain 2. Neuropathic pain 3. Headache Non-pain physical symptoms: breathlessness, nausea, constipation, asthenia, deconditioning anorexia Emotional / relational Including PTSD Existential and spiritual Financial and legal MORPHINE DOESN T WORK FOR ME! Opioid responsiveness Opioid Responsiveness Responsive Analgesia Side Effects Analgesia Side Effects Non-Responsive Factors that Cause Opioid Unresponsiveness Analgesia Side Effects Neuropathic type of pain Incident pain Tolerance Disease progression Drug-specific issues metabolites route of administration AllinaHealthSystems 4

5 What makes Neuropathy so unpleasant?? Activation What makes Neuropathy so unpleasant?? Diffusion What makes Neuropathy so unpleasant?? Wind-up Amplification neuron response Repetitive stimulation of spinal neurons evokes an increasing level of response NMDA receptor antagonists block this effect Hz---- Factors that Cause Opioid Unresponsiveness Morphine Metabolites Neuropathic type of pain Morphine Incident pain Tolerance Hyperalgesia liver Analgesia Disease progression Drug-specific issues metabolites route of administration M-3-G kidney M-6-G AllinaHealthSystems 5

6 Route of Administration Morphine More M3-G METHADONE More M6-G What s the right dose?: Morphine-to-Methadone Ratio Drug Interactions :1 8:1 3:1 Lowest dose Median dose Highest dose Dose Ratio Plonk s Rule Plonk s rule: (Morphine 15) + 15 Example: 200 mg/day oral morphine = 200/ = 28 mg/day oral methadone Decreased Methadone Levels Amitriptyline (Elavil) Carbamazepine (Tegretol) Estrogens (Premarin) Fosphenytoin (Cerebyx) HIV Antivirals Phenytoin (Dilantin) Rifampin Risperidone (Risperdal) Verapamil (Calan, Isoptin) St. John s Wort Increased Methadone Levels Cimetidine (Tagamet) Fluconazole (Diflucan), variconazole Methadone in Cirrhosis Elevated plasma levels (4x) were measured in a patient with cirrhosis and lung cancer Rifampin lowers methadone levels Wikimedia Commons AllinaHealthSystems 6

7 Good Things about Methadone Good oral absorption: 80% for methadone 40% for morphine 6-16% for meperidine Good bioavailability first pass through the liver takes out ~1/2 of the active drug Good Things about Methadone Multiple routes of administration PO/SL/Feeding tube/rectal IV/SQ (not compatible with other IV opioids) intrathecal/epidural Flexible dose forms liquid, dissolving tabs, tablets can be concentrated 1mg/ml >> 20+ mg/ml Good Things about Methadone $1,000 $995 Unique molecular structure Can be used in cases of morphine allergy hives, wheezing (not itching alone) Not cleared by the kidneys $800 $600 $400 $200 $0 $650 $345 $250 $39 Methadone Dilaudid MS-Contin Oxy-Contin Fentanyl Methadone: Cost of One Month of Therapy Less commonly used pain strategies Ketamine Lidocaine Intrathecal or epidural CHALLENGES IN CONTROLLING PAIN The case of the painful rib Palliative sedation AllinaHealthSystems 7

8 Altered pharmacology: The Case of the Painful Rib Difficulties taking oral meds This 54 year-old man with lung cancer presented with a painful rib. A metastasis in the rib was found on X-ray. The spot was injected with lidocaine and cortisone. He suddenly became unresponsive and apneic. After 3 days in the ICU he woke up and felt much better. Morphine, mg per day DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 National Cancer Institute Altered pharmacology Difficulties taking oral meds Wikimedica Commons Altered pharmacology WHY IS MY PATIENT STILL HURTING? AllinaHealthSystems 8

9 Pharmacologic causes Pharmacologic causes Too low a dose Too long an interval Relying on short-acting pain meds breakthrough pain Repeated The wrong diagnosis Nociceptive? Neuropathic? Headache? Inflammatory? Neglecting use of adjuvants Non-pharmacologic causes Lack of sleep Nausea Muscle pain Constipation Non-pharmacologic causes Infection Nonphysical pain: relational, spiritual, financial Dementia or delirium Tools at your command 1. Assessment 1. Pain assessment 2. Nursing observation 2. Treatment 1. Nonpharmacological therapies 2. Education AllinaHealthSystems 9

10 Fun Facts about Constipation OPIOID CONSTIPATION Opioids produce constipation by at least 3 mechanisms: They tighten the sphincters at the rectum and the ileo-colonic junction. They desynchronize normal peristalsis. They dehydrate the stool. Stool volume is about 1/3 rd non-food sources: Colon bacteria Colon cells normally shed from the mucosal lining If you re really constipated, you may not feel constipated Spectrum of opioids in constipation Prevent constipation Dilaudid/Oxycodone Morphine/Codeine Myenteric plexus Methadone/Fentanyl OpenStax College, Rice University Docusate Lubiprostone Prostaglandin E1 metabolite Activates chloride channels 8-24 mcg BID AllinaHealthSystems 10

11 Methylnaltrexone Indicated for opioid-induced constipation Dose 8-12 mg SQ Laxation within 4 hours 48% A LITTLE ABOUT NON-PAIN SYMPTOMS: Cachexia: Fatigue and Loss of Appetite 15% Placebo Methylnaltrexone Causes of fatigue and poor appetite Cachexia: The Metabolic Model Worry, losing sleep Unrelieved pain Chemotherapy or radiation Cachexia Tumor Products Cachexia Muscle loss Fat breakdown Tumor Products Loss of appetite AllinaHealthSystems 11

12 CACHEXIA AND FATIGUE: The Autonomic Nervous System Autonomic dysregulation Autonomic effects of cachexia Therapies with (some) evidence of benefit Symptom relief metoclopramide BDR suppositories ondansetron exercise cannabis Reversal of cachexia anti-tumor necrosis factor antibodies sympathetic agonistsclenbuterol, formoterol megesterol acetate fish oil Aerobic exercise as therapy for cancer fatigue Summary Death from serious illness can become highly medicalized Maximal performance Walking distance (m) Before After Before After Palliative care earlier rather than later helps people with serious illness apply their goals and values to the plan of care. Non-pain symptoms are as taxing as physical pain in serious illness. Dilaudid works for me, usually means that relief outweighs side effects. Neuropathic pain responds to traditional opioids when mild, but needs methadone and/or neuroactive meds when it is severe. AllinaHealthSystems 12

13 Summary Newly prescribed methadone requires careful observation for sedation as it accumulates in the first week. Careful nursing assessment of pain will reveal other causes of pain, as well as opportunities for nonpharmacological treatments. Beware of using fentanyl patches in thin or febrile patients. Opioid constipation can be treated, but it is better to prevent it. Cachexia is a total body metabolic and neurologic syndrome. OBJECTIVES 1. Name two ways palliative care improves outcomes in serious illness. It controls symptoms to improve quality of life It aligns the medical care to the patient s goals and values. 2. Identify two psychosocial factors that influence pain levels Lack of sleep Worrying about personal or financial issues 3. What assessments are most helpful in evaluating the patient whose pain is poorly controlled? Pain pattern: relief and duration of relief Functional pain scale REFERENCES Eric Anderson, MD Center to Advance Palliative Care: Bruce RD, et al. Pharmacokinetic drug interactions between opioid agonist therapy and antiretroviral medications: implications and management for clinical practice. J Acquir Immune Defic Syndr 2006; 41: Kharasch, Hoffer, Whittington, Sheffels, Role of hepatic and intestinal cytochrome P450 3A and 2B6 in the metabolism, disposition, and miotic effects of methadone. Clinical Pharmacology & Therapeutics (2004) 76, ELNEC End of life Nursing Education Consortium: C Ripamonti, L Groff, C Brunelli, D Polastri, A Stavrakis, and F De Conno. Switching from morphine to oral methadone in treating cancer pain: what is the equianalgesic dose ratio? Journal of Clinical Oncology :10, Oliver, Debra Parker, and William M. Plonk Jr. "End-of-Life Care in the Nursing Home; Simplified Methadone Conversion." Journal of palliative medicine 8.3 (2005): Beauverie, Patrick, Valérie Furlan, and Yves-André Edel. "Slow metabolism and long half life of methadone in a patient with lung cancer and cirrhosis." Annales de medecine interne. Vol Barber, Matthew D., et al. "Metabolic response to feeding in weight-losing pancreatic cancer patients and its modulation by a fish-oil-enriched nutritional supplement." Clinical Science 98.4 (2000): Temel, Jennifer S., et al. "Early palliative care for patients with metastatic non small-cell lung cancer." New England Journal of Medicine (2010): Daeninck, Paul J., and Eduardo Bruera. "Reduction in constipation and laxative requirements following opioid rotation to methadone: a report of four cases." Journal of pain and symptom management 18.4 (1999): AllinaHealthSystems 13