You Scream, I Scream, We All Scream for Morphine! Key Opioid Issues in Contemporary Hospice Practice

Transcription

1 You Scream, I Scream, We All Scream for Morphine! Key Opioid Issues in Contemporary Hospice Practice Mary Lynn McPherson, PharmD, MA, MDE, BCPS Professor and Executive Director, Advanced Post Graduate Education in Palliative Care Program Director, Online Master of Science and Graduate Certificate Program in Palliative Care Graduate.umaryland.edu/palliative Disclosure Statement No conflict of interest exists for any individual in a position to control the content of this educational activity. 1

2 Learning Objectives At the conclusion of this seminar, the participant will be able to: 1. Discuss the importance of medication review and deprescribing, including patient/family communication. 2. Describe pain management strategies in the face of substance abuse. 3. Describe current drug disposal regulations and anticipate future changes. Case 1 What s the sitch? Mr. Morganstern is a 58 year old man with end stage lung cancer being discharged from the hospital to home hospice. The patient is 5 8, 150 pounds and can swallow tablets and capsules. The patient is currently receiving: Transdermal fentanyl 50 mcg/h OxyContin 20 mg po q12h Hydromorphone 4 mg IV every 4 hours as needed (getting about 5 doses per day) Hydrocodone/acetaminophen 5/325 mg every 4 hours as needed (not using). What do you think about this analgesic regimen? 2

3 Cleaning up / questioning the opioid regimen What are some wacky opioid regimens that you ve seen? Multiple opioids More than one long acting Is TDF appropriate? Using only short acting opioids around the clock Case 1 What s the sitch? Mr. Morganstern is a 58 year old man with end stage lung cancer being discharged from the hospital to home hospice. The patient is 5 8, 150 pounds and can swallow tablets and capsules. The patient is currently receiving: Transdermal fentanyl 50 mcg/h OxyContin 20 mg po q12h So what would you do in this case? Hydromorphone 4 mg IV every 4 hours as needed (getting about 5 doses per day) Hydrocodone/acetaminophen 5/325 mg every 4 hours as needed (not using). What do you think about this analgesic regimen? 3

4 How do you have that conversation? SPIKES Having those conversations S setting P perception I invitation K knowledge E emotion S summarize recommendation Slides from McPherson, Walker, Pruskowski, Talebreza. Right Sizing Medication Regimens in Serious Illness: Doing the Prescribing and Deprescribing Dance 4

5 Communication Models Responding to Emotional Cues The NURSE mneumonic N Name it it sounds like you ve been worried about what s going on U Understand the core message: if I understand you correctly, you are worried about what to say to your family and how they will react R Respect/Reassurance at the right time: I m really impressed that you ve continued to be independent S Support: would you like me to talk to your family about this? E Explore: I notice that you re upset, can you tell me what you re thinking? Case 2 Ms. Johnson is a 48 year old woman with end stage breast cancer, admitted to hospice. She was admitted on MS Contin 30 mg po q12h with MSIR 15 mg po q4h prn additional pain. Her pain persisted and the morphine regimen was eventually increased to: MS Contin 75 mg po q12h MSIR 30 mg po q2h (using 3 4 times per day) She continues to rate her average pain as 7/10. Why does this plan not work?? What s the dealio? 5

6 11 What s the differential diagnosis? tale of six blind physicians and the elephant/ 12 6

7 It could be Opioid poorly responsive pain Type of pain; temporal pattern of pain (breakthrough) Opioid induced tolerance / Disease progression Opioid induced hyperalgesia Poorly managed opioid therapy Non physical pain 13 Ms. Johnson is a 48 year old woman with end stage breast cancer, admitted to hospice. She was admitted on MS Contin 30 mg po q12h with MSIR 15 mg po q4h prn additional pain. Her pain persisted and the morphine regimen was eventually increased to: MS Contin 75 mg po q12h MSIR 30 mg po q2h (using 3 4 times per day) She continues to rate her average Opioid poorly responsive pain pain as 7/10. Type of pain; temporal pattern of pain (breakthrough) Why does this plan not work?? Opioid induced tolerance / Disease progression What s the dealio? Opioid induced hyperalgesia Poorly managed opioid therapy Non physical pain 7

8 Opioid Myths and Misconceptions What crazy pants things have you heard patients, families, caregivers and maybe even other health care professionals say about opioids and pain management? Opioid Myths and Misconceptions Once you start with that morphine, she ll need more and more and more. People who need medications like morphine for pain control are always very ill and near death. Opioid tolerance, dependence and addiction are all the same thing. Pain medication always leads to addiction. Opioids very rarely lead to addiction. 8

9 Opioid Myths and Misconceptions Pain medications always cause heavy sedation. Some kinds of pain cannot be relieved. Pain and suffering cannot be avoided. Also, they build character. Effective pain management can be achieved on an as needed basis. Opioid analgesics should be avoided in older adults. I m not even sure older adults really even feel pain. Infants and children don t experience pain as adults experience pain. Opioid Myths and Misconceptions Morphine hastens death in a terminally ill patient Injectable morphine works better than morphine by other routes of administration. Heavy duty analgesics (e.g., strong opioids) should be withheld until death is imminent. A patient who is sleeping is not in pain. A patient who is watching television or laughing with visitors is not in pain. Alterations in vital signs are reliable indicators of pain in a patient. 9

10 What the heck happened? In the 1980 s the HIV epidemic drew attention to the undertreatment of pain In 1996 the American Pain Society declared pain the fifth vital sign (and VA) 1996 Purdue Pharma released OxyContin In 1998 Purdue released video I Got My Life Back This study was NOT evaluating the impact of chronic opioid therapy for chronic pain; their observation had little bearing on the risk of developing addiction with chronic use. Daniel Tobin, MD NEJM March 14,

11 Pain? No addiction risk? Go get the opioids!! Uh oh Free love, free opioids. Increased opioid induced deaths From inappropriate prescribing? From prescription misuse/abuse? From illicit opioids such as fentanyl? 11

12 unintended consequences The increase in opioid related mortality fueled by injudicious prescribing and increasing illicit use of both prescription and illegal opioids has led some clinicians to simplify their lives by discontinuing prescribing of opioid analgesics. (NEJM) Webmd.com/special reports/opioids pain/ /opioids pain?print=true These are strategies?? We re an opioid free practice DEA cuts manufacturing limits on opioids CDC releases guidelines on opioids and chronic pain Reduced use of opioids post operatively, in oncology practice, primary care Patient suffering, increased use of heroin, suicide 12

13 Finding Middle Ground. Is this the responsibility of the hospice team? Ten Steps of Universal Precautions in Pain Medicine 1. Make a diagnosis with appropriate differential 2. Psychological assessment including risk of addictive disorders 3. Informed consent 4. Treatment agreement 5. Pre and post intervention assessment of pain level and function Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):

14 Ten Steps of Universal Precautions in Pain Medicine 6. Appropriate trial of opioid therapy +/ adjunctive medication 7. Reassessment of pain score and level of function 8. Regularly assess the four A s of pain medicine 9. Periodically review pain diagnosis and comorbid conditions, including addictive disorders 10. Documentation Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2): Case 3 JB is a 43 year old woman admitted to hospice with end stage breast cancer. On admission to hospice she was receiving MS Contin 60 mg po q12h with MSIR 15 mg po q4h prn. She was using prn ATC. Patient complained of pain 8 10/10 since admission. MS Contin dose was escalated. Team decided to switch her to oral methadone, which was ordered and delivered. The morning the RN was going to educate on starting methadone patient had a severe pain crisis and was admitted to the hospice inpatient use. 14

15 Case 3 After a week inpatient, patient s pain was controlled on methadone 10 mg po q8h. Patient was discharged home. When RN arrived at patient s home half hour after patient arrived by ambulance, RN found all methadone was gone. Husband started to cry and confessed he drank the whole thing. I can t help myself. I m a drug abuser. Anything you bring in this home for my wife, I ll steal and take myself. I love my wife, but I just can t help myself. Wife says she knows she doesn t have much time left, and she wants to stay home with her three children, 10, 12 and 15 years old. Husband is hysterical. What are you doing to do? Step 1: Problem Identification Once the problem is identified, it s up to the team to determine: Whose problem is it? It is important for the hospice to understand it may very well be an organizational problem if the patient and/or family are selling medications the hospice is providing on the street. How is it a problem? Is this a safety, legal, ethical, medical, or financial problem? Who is involved? Is it only the patient, or are the family, paid caregivers, extended family, friends or even staff also involved? Giles C, St. Clair T. 4 th Joint Clinical Conference, April 10-12, Denver, CO 15

16 Step 2: Goals and Intervention Formulation Goals and interventions are important for all the team to formulate. The team should analyze 5 questions to develop their plan: What are we trying to achieve? What are all the options? What are all the limitations or obstacles? What are the consequences of doing nothing? It may be more appropriate to leave the situation alone, such as if the patient is actively dying. What are the consequences of possible choices? Giles C, St. Clair T. 4 th Joint Clinical Conference, April 10-12, Denver, CO Step 3: Building Interdisciplinary Coalition Communication of the plan with all members of the interdisciplinary team, especially the patient s physician, is crucial to assuring the goals are met and interventions followed. A point person or team leader for plan implementation should be appointed to assure adequate communication is maintained among team members. Giles C, St. Clair T. 4 th Joint Clinical Conference, April 10-12, Denver, CO 16

17 Step 4: Offering the Choices After goals and interventions have been agreed upon by all team members, the next step is communicating the choices to patient/family. Do during a family meeting. Communicate choices in a nonjudgmental fashion, set clear limits for how the situation will be handled. Negotiation should be minimized; only choices and consequences offered. Four choices should be offered. Giles C, St. Clair T. 4 th Joint Clinical Conference, April 10-12, Denver, CO Step 4: Offering the Choices Four choices should be offered: Managing medication, as prescribed. The patient and family will adhere to the prescribed regimen, and medications will be closely monitored by the case manager. Use of alternate medications and/or routes. Being home without medications and/or hospice. Out of home placement with medication and hospice. Giles C, St. Clair T. 4 th Joint Clinical Conference, April 10-12, Denver, CO 17

18 Step 5: Implementing the Choices and their Consequences All hospice staff should be informed of patient/family decision (including on call staff and volunteers). All relevant external supports or referrals (e.g., PT, medical supply companies) should also be notified of the plan to ensure implementation across all disciplines. Anticipate attempts at manipulation and have plan in place (e.g., no medications will be ordered at night or on weekends when different staff may be working). Giles C, St. Clair T. 4 th Joint Clinical Conference, April 10-12, Denver, CO Step 6: Evaluating the Effects Once the plan is in place, it will be possible for the team to evaluate the effects. There will be certain outcomes to expect such as: Improved accountability for medications No further seeking of medications within the system Involved parties report satisfaction or decreased concern Giles C, St. Clair T. 4 th Joint Clinical Conference, April 10-12, Denver, CO 18

19 Step 7: Doing it all again if the choice cannot be maintained If patient/family do not comply with the plan, such a lack of progress must be confronted promptly. Consequence to noncompliance would be the next choice on the list, assuring that: No second chances are given Original expectations are not altered Deadlines are not extended Giles C, St. Clair T. 4 th Joint Clinical Conference, April 10-12, Denver, CO Patterns of storage, use and disposal of opioids among cancer patients Survey of 300 adult outpatient cancer patients couples with CAGE questionnaire CAGE + in 58 of 300 patients (19%) 26 (9%) had a history of illicit drug use Storage 56 (19%) stored opioids in plain sight 208 (69%) kept opioids hidden but unlocked 28 (9%) locked their opioids 78 (26%) reported unsafe use, 9% sharing and 17% losing Disposal 223 (74%) were unaware of proper opioid disposal methods 138 (46%) had unused opioid at home Reddy A, et al. Oncologist 2014;19(7):

20 Basic Principles for Prescribing Controlled Substances to Patients with Advanced Illness and Issues of Addiction Choose an opioid based on around the clock dosing Choose long acting agents when possible As much as possible, limit or eliminate the use of short acting or breakthrough doses Use on opioid adjuvants when possible and monitor for compliance with those medications Use nondrug adjuvants whenever possible (e.g., relaxation techniques, distraction, biofeedback, TNS, communication about thoughts and feelings of pain) Kirsh KL, Passik SD. Cancer Investigation 2006;24: Basic Principles for Prescribing Controlled Substances to Patients with Advanced Illness and Issues of Addiction If necessary, limit the amount of medication given at any one time (e.g., write prescriptions for a few days worth or a weeks worth of medication at a time) Utilize pill counts and urine toxicology screens as necessary If compliance is suspect or poor, refer to an addictions specialist Kirsh KL, Passik SD. Cancer Investigation 2006;24:

21 Bereavement Issues Patient had a history of SA Bereaved may experience ambivalent feelings during grief process Relief that patient s behavior will no longer be a stressor to the family Guilt for feeling relief the patient has died Bereaved has a history of SA Risk for return to destructive behaviors Dy at al. Caring for patients in an inner-city home hospice: challenges and rewards. Home Health Care Management and Practice 2003:15(4): targets misuse of hospice drugs/ 21

22 What??? When will this start? Does the hospice have to have the permission of the family to dispose? What if they say no? Does the method of disposal change (like kitty litter or coffee grounds)? Or it is just the hospice employee taking possession? What hospice employees are eligible to dispose? Is it just for hospice, or does palliative care apply too? If you give a mouse some morphine 22

23 You Scream, I Scream, We All Scream for Morphine! Key Opioid Issues in Contemporary Hospice Practice Mary Lynn McPherson, PharmD, MA, MDE, BCPS Professor and Executive Director, Advanced Post Graduate Education in Palliative Care Program Director, Online Master of Science and Graduate Certificate Program in Palliative Care Graduate.umaryland.edu/palliative 23