TREATING CHRONIC PAIN in SERIOUSLY ILL PATIENTS

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TREATING CHRONIC PAIN inSERIOUSLY ILL
PATIENTS

• Jack McNulty,MD, FACP, FAAHPM
• President, Palliative Care Institute of Southeast
  Louisiana
• jackmcn12_at_bellsouth.net
• 985-373-1690 fax [phone]

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(No Transcript)
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OBJECTIVES

• Overcome the barriers to treating pain well
• Think of chronic pain as a disease
• Realize that pain is undertreated in the USA
• Know safe and effective Rx for pain
• Learn how to prescribe methadone or levorphanol
  for nerve or complex pain

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Definitions

• Chronic pain persistent (weeks, months, yrs)
• present at least 12 hr daily
• intensity at least 5 on a 0-10 scale
• Nociceptive Pain somatic or skeleto-muscular
  visceral pain
• Neuropathic Pain pain from CNS or peripheral
  nerve injury, difficult to relieve
• Complex Chronic Pain a mix of pain types, common
  in cancer, in postop. conditions, and in trauma

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Barriers to Treating Chronic Pain

• Education
• Experience
• Fear of Regulators
• Fear of Addicting Patients
• Fear of Opioid use in the Dying

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Education, Experience, and Regulators

• Doctors and nurses in the past were given little
  education and training about pain, and
  consequently are uncomfortable in prescribing
  opioids for treating pain, especially chronic
  pain.
• Changing attitudes and accepting advances in pain
  Rx may be difficult for many doctors and nurses.
• Fear of DEA, regulatory boards is excessive

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Fear of Addiction

• The risk of addiction is over-stated.
• The vast majority of patients with chronic pain
  are not addicts.
• The risk of becoming addicted is estimated at
  1-3 in the general pain population when there is
  no history of prior substance-abuse.
• 80 of addicts have inherited a genetic brain
  disorder, which is a life-long problem.
• Normal pain patients follow the rules.
• Addicts bend and break the rules.

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Addiction

• The problem in addiction and with substance
  abusers is not with the opioid, alcohol,etc .It
  lies within the abusers Brain.
• The reward center in the brain of addicts is not
  supplied with enough dopamine to enable addicts
  to feel pleasure as normal persons do.

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Addiction

• The addict seeks an activity or substance which
  boosts dopamine action at the reward center in
  the brain, which makes him feel good ( normal
  or better than normal).
• After the boost subsides, the addicts craves that
  dopamine high compulsively, even though the
  activity or substance may be damaging to him.

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Opioids and Respiratory Depression

• Patients receiving opioids for chronic pain and
  dyspnea tolerate large opioid doses without
  serious respiratory depression, when titrated
  appropriately.
• In contrast, opioid-naïve patients should be
  closely observed when they receive opioids, as
  their respiratory center has not yet developed
  tolerance to opioids.

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Overcome the Fear of Using Opioids in the Dying

• Serious resp. depression is rare in patients
  being treated for chronic pain. If oversedation
  does occurs, sleepiness occurs first. Observe
  closely, and if stable, hold opioid until awake,
  then resume at a lower dose and/or dosing
  interval, or change the opioid.
• Evidence-based studies indicate that judicious
  opioid use in the dying does NOT hasten death,
  but allows them to live in comfort until they
  die.
• The benefits of opioids greatly out-weigh risks.

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Morphine Approved for Chronic Refractory Dyspnea

• The American Thoracic Society and the American
  College of Physicians approve the use of morphine
  and other opioids for managing chronic refractory
  dyspnea.
• The Longitudinal Pattern of Response When
  Morphine is Used to Treat Chronic Refractory
  Dyspnea Currow D, et al J. Pall. Med 2013
  16(8) 881-886
• American College of Physicians consensus
  statement on the management of dyspnea in
  patients with advanced lung or heart disease
  Mahler DA et al Chest 2010137674-691
• American Thoracic Society Committee on Dyspnea
  Update on the mechaniams, assessment, and
  management of dyspnea Parshall MB, et al Am J
  Respir Crit Care Med 2012185435-452

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How to Manage Pain in Seriously Ill Patients
Who Might Die

• Difference between Acute and Chronic Pain
• Assessing Chronic Pain
• Treatment of Chronic Complex Pain
• Specific Opioids
• Workshop on Equianalgesic Opioid conversion

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Acute Pain

• Pathway for transmission of acute pain in spinal
  cord and CNS is conventional.
• Duration of acute pain is short.
• Endorphins and enkephalins are released by CNS to
  block pain perception by activating mu and kappa
  receptors in the dorsal horn of the spinal
  cord.All of the opioids are effective to relieve
  acute pain in this way.

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Changing from Acute Painto Chronic Pain

• Acute pain causes release of the neurotransmitter
  glutamate in the dorsal horn of the spinal cord.
• Glutamate binds to AMPA receptors in cells of the
  dorsal horn, which triggers pain signals to the
  CNS
• When AMPA receptors are saturated by excess
  glutamate, normally inactive N-methyl-D-aspartate
  (NMDA) receptors in the spinal cord become
  activated by the excess glutamate.
• This begins the change from acute to chronic pain

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Acute and Chronic PainBrookoff,D1) Chronic
Pain A New Disease? Hosp Pract 35(6)
Minneapolis,MN 45-59
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Consequences of N-Methyl-D-Aspartate Receptor
Activation

• Windup
• Neural Remodeling
• Activation of Neurokinin-1 Receptors
• Afferent becomes Efferent
• Neurogenic Inflammation

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Windup

• Less glutamate is required to transmit pain
• More anti-nociceptive input required to stop it
• Endorphins cannot keep up with demand
• Pain relievers lose their effectiveness
• Result More intense pain, harder to relieve

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Neural Remodeling

• Activation of NMDA receptors cause neural cells
  to sprout new connective endings
• adds new dimensions to old sensations
• emotional component of pain can increase
• new connections channel signals to the reticular
  activating system of the brain
• RESULT Diffuse, hard to localize pain

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Activation of NK-1 Receptors

• NMDA receptor activation causes nociceptors to
  release the peptide neurotransmitter Substance P
• Substance P binds to Neurokinin-1 receptors
• This amplifies the pain signal
• Stimulates nerve growth and regeneration

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Substance P

• Induces production of the c-fos oncogene
• the biochemical footprint for chronic pain
• marker for central hyper-sensitization
• C-fos
• levels go higher up the spinal cord with
  persistence of pain
• reaches the thalamuspain is untreatable
• Pain is no longer confined to the original site
  in some patients
• Detected in fibromyalgia in lab studies

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Afferent becomes Efferent

• NMDA receptor activation causes some afferent
  neurons to carry signals backwards to
  nociceptors, which can establish a dorsal root
  pathological reflex
• Substance P is released at the periphery causing
  inflammation and promotes the cyclic nature of
  chronic pain

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Neurogenic Inflammation

• A tissue reaction caused by Substance P and nerve
  growth factor, affecting synovia and other
  connective tissue.
• Doesnt depend on granulocytes or lymphocytes
• Substance P causes de-granulation of mast cells,
  releases bradykinin, nitric acid.

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Neuropathic Pain

• Damage to sensory nerves
• can cause neuropathic pain syndromes
• insensitive to anti-nociceptive suppression by
  conventional opioids.
• After tissue injury
• A Fibers- large myelinated nerves that carry
  touch sprout new terminal branches
• These synapse with pain-sensing cells in the
  OUTER dorsal horn which lack opioid receptors,
  thus endogenous and exogenous opioids are
  ineffective
• examples of pain poorly responsive to opioids are
  phantom limb and diabetic neuropathy

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Assessing Chronic Pain

• Detailed description of pain ( from patient,
  caregiver, staff ) is it somatic, visceral,
  neuropathic, or mixed? Location? Intensity?
• What makes it better or worse
• Effect on emotional, social status
• How much impairment of function?
• Review diagnostic and lab data
• Reassess often to adjust treatment

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Pain near the End-of-Life

• Chronic pain more complex and difficult to
  treat than acute pain
• Somatic and Visceral pain (Nociceptive ) usually
  opioids and adjuvants are effective
• Neuropathic pain NMDA-receptor blocking opioids
  ( levorphanol, methadone) or ketamine work best.
  Adjuvants are helpful, often over-rated.

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Treating Pain with Opioids

• Use the World Health Organization
• 3-step analgesic ladder
• Step 1 Mild analgesics APAP, NSAIDs
• Step 2 Moderate analgesics Codeine,
  Tramadol Hydrocodone/APAP, Oxycodone/APAP
• Step 3 Strong Opioids

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WHO 3-stepLadder
3 severe
Morphine Hydromorphone Methadone Levorphanol Fenta
nyl Oxycodone Adjuvants
2 moderate
A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodei
ne Tramadol Adjuvants
1 mild
ASA Acetaminophen NSAIDs Adjuvants
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Morphine

• Usual 1st. choice for moderate, severe pain.
  Begin low, 15mg q 3-4 hr. Titrate, reassess
  often.
• No ceiling amount as long as tolerated.
• Resp. depression rare in chronic pain patients.
• High doses metabolites cause nausea,
• dysphoria, muscle jerks, seizures.

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Dilaudid- hydromorphone

• Beginning dose 2-4 mg q 3-4 hr. Very effective,
  similar to MS.
• Less nausea. No ceiling. Often used orally for
  breakthrough pain and i.v.
• No sustained-release form.
• 2 mg 8 mg MS
• Toxicity similar to morphine

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Oxycodone

• Starting oral dose 5-10 mg q 3-4 hr. Very
  effective.
• Less nausea, less troublesome metabolites. With
  ASA and APAP (Percodan, Percocet), ceiling is
  limited.
• Expensive sustained-release form (Oxycontin), no
  ceiling. Watch for illegal diversion. Oxycontin
  10,20,40,80 mg.
• Liquid concentrate 20mg/ml is useful
  sublingually or buccally in the dying, similar to
  MS oral concentrate (Roxanol).

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Duragesic (Fentanyl)

• Duragesic patch use care in opioid- naïve
  patient, only after pain controlled by
  short-acting opioid. One patch used for 72 hr.
• Fever increases absorption. Avoid placing patch
  on areas without subcut. fat.
• 10-12 hr delay in onset and offset due to skin
  fat reservoir absorption.
• Early tolerance may limit use in severe pain

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Methadone

• Methadone, a synthetic opioid developed in 1940
  has been used worldwide for pain relief. The
  development of sustained-action morphine,
  oxycodone, and fentanyl in the 80s, relegated
  methadone to use mainly in substance-abuse until
  recently. Used for neuropathic and complex pain,
  it is now easy and safe to convert from morphine
  and other opioids to methadone.

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Levorphanol

• The forgotten opioid, an excellent drug,
  Levorphanol, like Methadone, was no longer
  marketed after 1990. It is available now in 2mg
  tablet ( Rorer). Evidence-based study in 2003
  effective in relief of neuropathic pain.
• Personal experience and published case studies
  confirm its value (JPM, 2007, 2009)

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Levorphanol

• NMDA-receptor blocker and mu-opioid agonist.
  Long half-life dose 6,8,or 12 hr
• 2 mg tablet equal to 8-15 mg morphine p.o
• Excellent alternative to methadone no stigma no
  effect on QTc no effect on cytochrome P450
  pharmacokinetics.
• Easiest drug to convert to and from methadone.

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Short-acting Opioids to Begin Rx or for
Breakthrough Pain q 3-4hr

• Hydrocodone/ APAP oral tabs and liquid 5-10 mg
  po q 4 hr around-the-clock
• Oxycodone/APAP or Oxycodone oral liq.or tabs 5-10
  mg q 4hr ATC
• Hydromorphone oral tabs,liquidiv suppos. 2-4
  mg q 3-4 hr ATC
• Morphine oral tabs,15mg, and oral conc. solution
  20mg/ml iv or s.q. rectal suppos. Oral conc.
  most useful at EOL, buccally or subling. 5-10 mg
  q 2-4 hr prn.

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Long-acting Opioid Preparations

• Morphine sustained- release (q 8-12 hr)
  (MsContin)24hr(Avinza)12-24 hr (Kadian)
• Oxycodone sustained- release (q 8-12 hr)
  (Oxycontin and generic) Oxymorphone (
• Fentanyl transdermal patch (q 72 hr )
  (Duragesic and generic)
• Methadone ( q 6-12 hr )
• Levorphanol ( q 6-8 hr )

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Adjuvants for Neuropathic Pain

• ANTICONVULSANTS
• Gabapentin, Lyrica, Valproic Acid, Lamotrigine,
  Tegretol
• TRICYCLIC ANTIDEPRESSANTS
• Amytryptiline Imipramine
  Nortryptiline Desipramine
• OTHERS Duloxetine ( Cymbalta )
• Lidocaine

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Adjuvants for Nociceptive Pain

• Tricyclic Antidepressants (desipramine or
  nortryptiline preferred)
• NSAIDS
• Corticosteroids ( dexamethasone preferred)
• Metoclopramide (for visceral pain)

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WORKSHOP CONVERTING OPIOIDS

• Palliative Care Institute of Southeast Louisiana
• 752 N. Columbia St., Covington, LA 70433
• John P. Jack McNulty, MD, FACP,FAAHPM
• jackmcn12_at_bellsouth.net 985-373-1690
• George Muller, R.Ph, Consultant,
  Compounding Pharmacist
• george_at_mullercbs.com

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Prescribing Opioids for Chronic Pain- General
Principles

• Use WHO pain ladder to select analgesic
• Around-the-clock, q. 3-4 hr. ( not 4-6 hr)
• Assess frequently, adjust dose to relieve pain
• When pain controlled,add up total opioid taken q.
  24hr. Select long-acting opioid q. 12 hr.
• Use short-acting opioid for breakthrough pain
  prn.
• Use one short- and one long-acting
• Reassess to titrate dose q 1-2 days until stable.

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How to Convert From One Opioid to a Different
Opioid

• Add up all the opioids currently prescribed in
  the previous 24 hrs.
• Use the equi-analgesic tables to convert all
  opioids to their oral morphine equivalent in the
  previous 24 hrs.
• Choose a new opioid, and use the tables to
  calculate the 24hr dose of that opioid
• Use a long-acting, and a short-acting version
  (if available), dosed appropriately for that
  opioid

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Equianalgesic Doses if Morphine 10 mg p.o.

• Hydromorphone 2 mg- 2.5 mg ( I use 2.5 mg)
• Oxycodone 5-10 mg ( I use 10 mg)
• Hydrocodone 15 mg
• Codeine 60 mg
• Ultram(tramadol) 50 mg
• Demerol(merperidine) 50 mg
• Fentanyl(duragesic) see slide 44
• Levorphanol see slide 45
• Methadone see slide 46

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Fentanyl converting to and from Morphine

• 12 mcg/hr Transderm patch 25 mg
• oral Morphine per 24
  hr.
• 25 mcg/hr Transderm.patch 50 mg
• oral Morphine per 24
  hr.
• 50 mcg/hr Transderm.patch 100 mg
• oral Morphine per 24 hr.
• 75 mcg/hr Transderm.patch 150 mg
• oral Morphine per 24 hr.
• 100 mcg/hr Transderm.patch 200 mg
• oral Morphine per 24 hr.

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CONVERTING TREATMENT from oral MORPHINE
to oral LEVORPHANOLMorphine (MS)/24 h to
Levorphanol (LEV)/24 h

• MS lt 100 mg 121 (12 mg MS1 mg LEV)
• MS 101-300 mg 151 (15 mg MS1 mg LEV )
• MS 301-600 mg 201 (20 mg MS 1 mg LEV )
• MS 601-800 mg 251 (25 mg MS 1 mg LEV )
• MS 801-1000 mg No data
• MS gt 1000 mg No data

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MD Anderson Ratios to Convert Oral Morphine to
Oral Methadone

• Morphine Equivalent Daily Dose (oral)
• lt30mg ratio MS to Methadone 21
• 30-99
  41
• 100-299
  81
• 300-499
  121
• 500-999
  151
• gt1000
  201

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1 Hydrocodone converted to Morphine

• 15 mg hydrocodone 10 mg oral morphine
• Patient taking 15 mg hydrocodone q 4 hr atc
  equals 90 mg/24hr.
• 90 mg hydrocodone 60mg morphine/24hr, or 10 mg
  morphine orally q 4hr ATC, and titrate up if
  needed.

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2a Convert Vicodin and Percocet to Fentanyl Patch

• 60 yr male with chronic back pain not helped by
  Vicodin 10mg every 4 hr. and by Percocet 10mg 6
  times daily
• Convert first to morphine equivalent/24hr
• From chart60mg hydrocodone 40mg MS
  Oxycocone 60mg 60mg MS
• MS equivalent 100 mg/ 24hr.
• Convert to Fentanyl next slide

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2b) Convert Morphine (oral) to Fentanyl patch

• Patient is receiving 100 mg oral morphine
  equivalent poor relief from pain
• Use the conversion chart for morphine to
  fentanyl
• 100 mg oral morphine 50 mcg/h patch applied
  every 72 hr. Onset and offset of effect of
  fentanyl is about 10-12 hours.

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3a Convert Oral morphine to i.v.Dilaudid

• Oral morphine dose is 360 mg in 24 hr.
• Convert first to oral dilaudid 1 mg dilaudid 4
  mg oral morphine divide 360 by 4 90 mg oral
  dilaudid.
• 1 mg i.v. dilaudid 5 mg oral dilaudid
• Divide 90 mg oral dilaudid by 5 16 mg i.v.
  dilaudid in 24 hr.
• Quick way Divide Morphine by 20 16 mg

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3b Convert iv Dilaudid back to Morphine oral
equivalent

• Dilaudid iv dose in 24 hr 16 mg
• Convert from iv dilaudid to oral dilaudid 1
  mg iv 5 mg oral dilaudid 16x5 90 mg
• Convert oral dilaudid to oral morphine 1mg oral
  dilaudid 4 mg oral morphine
• 90 mg oral dilaudid 90 x 4 360 mg oral
  morphine/24 hr.

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4aChronic Neuropathic Pain

• Attorney, age 46 ulnar neuropathy due to
  ischemia during long coronary bypass. Pain
  lancinating and burning, score 5-7, left forearm
  and hand, with interosseus atrophy.
• No relief with gabapentin, hydrocodone,
  oxycodone. Unable to work effectively.
• Convert to Levorphanol from 48 mg MS
  equivalent/24 hr

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4b Convert to Levorphanol

• From conversion chart, the ratio of morphine to
  levorphanol 121 in this case.
• 48 mg MS divided by 12 4 mg Lev./ 24 hr
• Patient declined dose 1mg tid allowed bid.
• After day 1, lancinating pain stopped, but
  burning persisted. 2 mg q 12 hr relieved his pain
  thereafter.

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Prescribing Very-Low Dose Methadone

• New evidence very-low methadone 2.5 mg morning
  and night blocks the NMDA receptor effectively,
  suggesting that the more controversial higher
  doses of methadone can be avoided by using other
  strong mu agonist opioids ( morphine, etc) as
  needed to control chronic pain. Haloperidol was
  effective adjuvant in small dose.
• J Pall Med2013,16 ( June)

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Levorphanol or Methadone?

• Levorphanol advantages No stigma, no ECG
  prolongation of QTc, predictable half-life, very
  few drug interactions. No bad press and drug
  industry misinformation.
• NMDA-receptor blocker like methadone mu and
  kappa agonist like morphine, oxycodone,
  hydromorphone. Forgotten!

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5a Unrelieved back, chest, abdominal pain in
cancer patient

• Current opioids prescribed in past 24 hours
• Fentanyl patch 50 mcg/hr q 72 hr
• Dilaudid 1mg iv x 4 doses 4 mg iv.
• CONVERT to 24hr oral morphine equivalent
• Fentanyl 50mcg/hr 100mg oral MS/24h
• Dilaudid 4 mg x4 x5 80 mg oral MS/24h
• CONVERT to Oxycodone from 180mg MS

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5b Converting Morphine- equivalent. to Oxycodone

• From chart,1mg oxycodone1mg morphine
• Patient 180 mg Morphine equiv./ 24hr
• Patient converts to 180mg Oxycodone/24 hr
• Dose Oxycodone ER 90 mg p.o. q 12 hr use Oxy
  IR 5 mg q 4 hr prn breakthrough.

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5c Convert same patient to Methadone

• Patient was receiving
• Fentanyl patch 50mcg/72 hr
• Dilaudid 1 mg iv x 4 doses 4 mg iv
• Convert to oral morphine equivalent/ 24 hr
• Fentanyl 50mcg 100 mg oral MS/ 24 hr
• Dilaudid 4 mg iv x 4 x 5 80 mg MS/ 24hr
• Convert Methadone from 180 mg MS/24hr

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5d Convert Morphine oral equivalent to Methadone

• From the conversion table to and from morphine to
  methadone, the ratio of MS to methadone in this
  case is 81.
• 180 mg oral MS/ 24 hr divided by 8 22.5 mg oral
  methadone in 24 hr.
• Dose Methadone 7.5 mg orally q 8 hr use oral
  dilaudid 2mg q 3-4 hr prn breakthrough pain or
  use 2.5 mg methadone q 4 hr prn.

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6a Severe Neuropathic Pain Converted to Methadone

• Female, age73, has severe neuropathic pain due to
  cancer of tongue. She receives, via PEG, 170 mg
  morphine oral concentrate every 3 hr. Oral
  morphine equivalent/24 was 170 mg x 8 doses
  1,360 mg. Surprisingly, she was physically
  active, gardening and driving. Convert Methadone

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6b Conversion Methadone

• From the chart to convert morphine to methadone,
  obtain the ratio of MS to methadone when the oral
  morphine equivalent is 1000 (or more) mg/24hr
  201
• Divide the Morphine equivalent dose by 20 1320
  divided by 20 68 mg oral methadone in 24 hr.
  Use Methadone 20 mg q 8hr by PEG 5 mg
  Methadone q 4 hr breakthrough

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Symptom Control Kit

• Morphine solution 20mg/ml (subling) (15ml)
• Lorazepam Oral Conc. 2mg/ml buccally (15 ml)
• Phenergan tabs 25 mg (4)
• Phenergan suppository 25 mg (2)
• Chlorpromazine suppository 25mg (2)
  
• Haloperidol tabs 2mg (6) nausea, agitation
• Atropine eye drops 1 subling or in eye (5 ml)
• Tylenol suppository 500 mg (2)

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Summary

• The standard of care for the treatment of pain is
  changing every year.
• Pain, particularly chronic pain, is undertreated
  by most physicians.
• Non-interventional pain treatment is safe,
  effective, and cost-efficient.
• Most primary care MDs can treat most patients
  with chronic pain, whether malignant or
  non-malignant. Mentor is helpful with complex
  case.
• Palliative Care team can help relieve complex
  chronic pain in seriously ill suffering patients.

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Case 1

• 86 yr WF, readmitted from nursing facility
  dementia, debility, dehydration, UTI, sacral and
  heel decubiti, 3rd hospitalization in 3 mo.
  Grimaces and cries out when turned and bathed.
  Lortab elixir 5 mg q 6hr not helpful.
• Rx parenteral fluids, antibiotics, iv morphine,
  haloperidol, wound care, Foley
• Sepsis worsens, more agitation, family notified
  of decline and asks for comfort care at home with
  hospice.

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Palliative Care at Home with or without
Hospicefor Case 1

• Hospice or palliative care team assessment
  develop plan of care with MD
• Pain Morphine oral conc. 20mg/ml 0.25 ml (5 mg)
  buccally q 2-4 hr prn pain titrate up 0.25 ml
  stepwise as needed
• Haloperidol oral conc. 2mg/ml. 1-2 mg q 4-8 hr
  buccally, for agitation or nausea.
• Lorazapam oral conc. 2mg/ml 0.5-2.0 mg may or
  may not be helpful for anxiety.

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Alternative Rx for Case 1

• Dont use Fentanyl patch until stable pain
  control with short-acting opioid- remember
  25mcg/hr is equal to 50mg oral morphine/24hr
• Oxycodone oral conc. 20mg/ml SL or buccally
• Hydromorphone 2mg tabs(crushed) or oral solution,
  1-2mg q 3-4 hr.
• Levorphanol 2mg tab (crushed) ½ tab q 8hr subling
  or oral conc. 2 mg/ml
• Methadone 2.5mg (crushed) or oral conc.q 12hr

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Case 2Lung cancer with spread to Pleura and Ribs

• 61yr WM, Dx 1 mo., seen in Onc. Clinic Pain at
  7, aching, sharp with activity and with cough.
  Lortab10 q 4-6 hr prn not helping over past 2
  wks.
• Percocet 5 one or two q 4hr ATC helps after 3
  days taking 8 tabs/ 24 hr.(40 mg in 24 hr)
• Convert to Oxycontin 20 mg q 12 hr,and 1 Percocet
  q 4 hr prn breakthrough pain.

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Case 2 Worsens

• Despite aggressive Rx, he developes mets to liver
  and spine pain becomes severe, with somatic,
  visceral, and neuropathic elements
• Oxycontin increased stepwise, 80 mg q 8hr
• No relief, so Dilaudid by PCA pump, and finally
  an intrathecal pump is helpful until he becomes
  septic and pump is removed.

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Case 2 near- terminal

• Dilaudid PCA not controlling pain 2 mg/hr plus
  20mg demand, for total 68mg/24hr.
• Morphine equivalent68 x201,360 mg po
• Convert to Methadone conversion ratio is 20 to
  1, so Methadone dose is 68 mg in 24hr
• Could dose po 20mg at 6am and 2pm and at 10pm, or
  half that dose q 8hr subcut. Reassess often to
  adjust dose up or down,

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Case 3End-stage COPD

• 78yr WF, smoker, anxious and fearful, housebound,
  oxygen-dependent, on nebs, prednisone, in and out
  of hospital with pneumonia, gets frequent bouts
  of dyspnea.
• She and family are afraid of narcotics
  (addiction, hastening death).
• Lorazepam helps some with anxiety and
  hyperventilation, but sx worsen.

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Case 3 Comfort

• Educating family and patient by nurse and doctor
  that benefit of Morphine is great and risk is
  very small takes time and diligence
• They finally agree with a test dose of 5mg,
  either oral conc. or MSIR tab, when in distress
  and with nurse present
• In 30 min, patient gets calm, more relaxed, with
  much better relief of dyspnea, and thereafter she
  allowed morphine prn for dyspnea or pain.

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Case 4 Breast Cancer with Spread to Bone and
Liver

• 54 yr BF admitted to Hospice from hospital with
  constant mod.severe pain in upper back, rib cage
  and upper abdomen.
• She was on a Morphine PCA pump, and was
  converted to MsContin 90mg q 12hr, with 30mg MSIR
  q 4hr prn breakthrough pain.
• Over next mo., pain increased despite 600mg
  MsContin in 24 hr. Muscle spastic contractions
  develop, signalling morphine toxicity Must
  rotate to another opioid ( Dilaudid).

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Case 4 Side-effects

• Dilaudid tried orally, then by PCA pump, but
  metabolites of Dilaudid cause similar
  side-effects, leading to seizures. Must calculate
  rotation to another opioid ( Levorphanol) and
  stop Dilaudid. Dilaudid dose is equal to 480 mg
  oral morphine in 24 hr. Consultant rotates her
  to oral Levorphanol. Ratio of MSLev is 201 in
  this case, so Lev. dose is 24 mg/ day, or 6mg q
  6 hr. Pain reduced, with no adverse effects