Pain Control at the End of Life

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Pain Control at the End of Life

• By
• Dr Marie Joseph MB BS FRCP
• Medical Director Consultant in Palliative
  Medicine
• St Raphaels Hospice, Surrey
• and
• Macmillan Consultant, Epsom St Helier
  Universities NHS Trust
• mariejoseph_at_straphaels.org.uk
• March 2009

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Content

• Allaying post-Shipman anxiety
• Pain and distress in the dying
• The WHO analgesic ladder
• Principles of opioid therapy
• Cardinal features of opioid toxicity
• Opioid switch
• Opioid equivalences
• Opioids in renal failure
• Providing comfort in the dying stage
• Summary

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Allaying Post-Shipman anxiety

• How much is too much?
• Pressure from distressed relatives
• The doctrine of double effect
• Death due to disease, (not due to
  drug)...opposite of euthanasia
• Regular, patient supervision/professional support

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Pain and distress in the dying patient

• Escalating/unabating physical pain
• Emotional pain of leaving loved-ones behind
• Inability to communicate
• Yearning for comfort and dignity
• Inevitable carer/professional distress

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The WHO Analgesic Ladder
Opioid for moderate to severe pain Non-opioid
Adjuvant
Opioid for mild to moderate pain Non-opioid
Adjuvant
Non-opioid Adjuvant
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Principles of opioid therapy

• Unstable pain requires titration with regular,
  4-hourly, short acting opioid same dose PRN
• Always use appropriate laxative (i.e. Softener
  and stimulant e.g. Movicol/Codanthramer)
• Approximately 1/3rd need anti-emetic therapy (if
  prone to migraine/vestibular disorder)
• Increase dose by 30-50 if pain inadequately
  controlled (and patient not opioid toxic)
• PRN dose is 1/6th of the total 24 hr dose

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Cardinal Features of Opioid Toxicity

• Excessive drowsiness
• Myoclonic jerks
• Insect-type visual hallucinations
• Pin-point pupils
• Caution May be opposed by anti-cholinergic
  medications e.g. Cyclizine, Amitriptyline)
• NOTE Respiratory depression virtually never
  encountered with due vigilance as above.

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Opioid switch

• Indications
• Inadequate analgesia OPIOID toxicity
• Idiosyncrasy to one type of OPIOID
• e.g. not uncommonly, MORPHINE OXYCODONE in
  neuropathic pain

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Opioid equivalences
½
ORAMORPH 15mg ? oral Oxynorm 7.5mg
?
1/3 DIAMORPHINE sc 5mg
?
1/10 ALFENTANIL sc 500mcg
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Opioid equivalences cont....

• Durogesic (Fentanyl) 12mcg patch every 72 hours
• ? Oramorph 5-10mg 4
  hourly
• Butrans patch weekly(BUPRENORPHINE)
• (5mcg 10mcg 20mcg)
• ....... Entirely STEP 2 of WHO analgesic
  ladder
• Buprenorphine 35mcg Matrix patch (Transtec)
• every 72 hours or twice a week
• ? Oramorph 5-10mg 4
  hourly

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Opioids in renal failure

• Fentanyl/Alfentanil safer
• If using Morphine
• Caution
• ? decrease dose and frequency
• If using Alfentanil in CSCI (continuous
  subcutaneous infusion)
• ? Dose is 1/10th of Diamorphine dose
• ? Use Oxycodone SC prn for breakthrough
  analgesia

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Providing comfort in the dying stage

• PAIN ? Use Diamorphine via CSCI
• (1/3rd of 24
  hour oral Morphine dose)
• 
  OR
• Initially
  5-10mg/24 hours if Opioid Naive
• RESTLESSNESS ? Exclude distended urinary bladder
• ? Attend to
  spiritual needs
• ? Use Midazolam
  via CSCI
• (10-20mg/24
  hours ...100mg/24hours)

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Providing comfort in the dying stage .... Cont.

• VOMITING ? Use Levomepromazine via CSCI
• 
  (initially 3.125-6.25mg/24 hours
• ......75mg/24 hours)
• LUNG SECRETIONS ? Use Hyoscine Hydrobromide
  via CSCI (initially 0.6-1.2mg/24
• hours ... 2.4mg/24 hours)
• Note - Regular patient review
• - Comfort family
• - Support inter/disciplinary team

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Summary

• OPIOIDS are safe and effective in the dying
• Importance of familiarity with Principles of
  opioid therapy
• Regular patient review essential
• Reassurance of Specialist Palliative Care Team
  support always

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Thank you