Pain Management at the End of Life

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Pain Management at the End of Life

• The Appropriate use of Opioids and what to do
  when they dont work

David M. McGrew, MD Medical Director - Hernando
Pasco Hospice Charter Member - American Academy
of Hospice and Palliative Medicine President -
Florida Chapter AAHPM FCPI - Central Region
Chair 1998 FHI - Physician Leadership Group
Chairman
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Pain - Why discuss it?

• Pain is a more terrible lord of mankind than even
  death itself
• Albert Schweitzer

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Pain Defined

• Unpleasant Somato-Psychic Experience

NO FUN
It affects the mind
It originates in the body (most of the time)
It is what the patient says it is
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TOTAL PAIN
SOMATIC INPUT
ANXIETY
ANGER / EMOTION
DEPRESSION
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Assessment

• History
• Physical
• Diagnostic Studies
• Types of Pain
• Cause
• Pattern

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Assessment - History

• Separate each site of pain
• site
• quality
• timing
• radiation
• severity
• aggravating / palliating factors
• impact on sleep, mood, function

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Assessment - Physical Examination

• Active and Passive Range of Motion
• Allodynia / Hyperesthesia
• Tenderness

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Assessment - Diagnostic Testing
JUST SAY NO
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Assessment - Types of Pain

• By Cause
• Bone
• Inflammatory
• Neuropathic
• By Pattern
• Lancinating
• Incidental to movement

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Opioids

• Choices
• Potency
• Class
• Route
• Cost
• Dosing
• Changes

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Narcotic Equivalence
McGrew's Maxim

• 10 mg Hydrocodone
• 10 mg Oxycodone
• 10 mg Morphine
• 1 mg Hydromorphone
• 100 mg Meperidine
• 120 mg Codeine
• 1 mg sc/im/iv 3 mg po

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Give em a shot!

• Preferred Routes
• Oral
• Rectal
• ? Transdermal
• SC
• IV
• Epidural
• Intrathecal
• IM

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Principles of Dosing

• Prevent Pain - Dont Chase It
• Give enough RTC that PRN
• Give equivalent daily dose RTC and PRN
• If using MSO4 180 mg daily RTC (60 mg q 8h) then
  allow up to 180 mg daily in rescue dosing (30
  mg q 4h)

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Inadequate Dosing

• How do you know?
• The patient is still in pain !
• When have you gone too far?
• Side effects outweigh benefits !
• (notice no comment on dose)

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Re-Assessment

• The Marks of Success
• Pain controlled to patients satisfaction
• Minimal or no functional impairment
• Identifying the failures
• Continued pain with unacceptable or untreatable
  side effects
• Significant functional impairment

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Narcotic Resistant Pains

• Bone Pain
• Prostaglandin Mediated
• Responds well to NSAIDs
• Neuropathic Pain
• Steroids, Tri-cyclics, Anti-convulsants

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Other Narcotic Resistant Pains

• Deafferentation
• Headaches
• Muscle Spasm
• Tenesmoid (Bowel / Bladder)
• Incident to movement
• Decubitus

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Adjuvants

• Steroids
• NSAIDS
• Anti-convulsants
• Anti-depressants
• Neuroleptic Agents
• Clonidine
• Hydroxyzine

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Non-Medication Solutions

• Relaxation
• Stress Management
• Redefining meaning of pain