PAIN MANAGEMENT AND END-OF-LIFE CARE
| PALLIATIVE CARE —Steven Z. Pantilat, MD, Associate Professor of Medicine, Project on Death Faculty
Scholar, University of California, San Francisco, School of Medicine, and Director, Palliative Care Service and
Palliative Care Leadership Center, Mofitt-Long Hospital, San Francisco
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| Death in America: most people die in hospitals, alone and in pain; “doesn’t have to be this way”; we have tools
to help people achieve better end of life; goal of care to relieve as much suffering as possible for patients and
families; >2 million deaths annually; life expectancy at birth 75.5 yr of age; leading causes of death remain heart
disease, cancer, and stroke
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| Site of death: hospitals—53%; varies from ≈30% in Oregon to ≈75% in New York City; nursing homes—24%;
number rising; home—23%; represents <50% of those who would prefer to die at home; hospice—25% use
hospice; number small compared to potential benefit; patients and families say, “I wish you had referred me
sooner”
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| Avoiding hospitalization: potential problems leading to hospitalization (eg, infection, pneumonia) often preventable
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| Definition of palliative care: comprehensive interdisciplinary care, focusing primarily on promoting quality of
life for patients living with terminal (or serious chronic) illness and for their families, assuring physical comfort
and psychosocial support; simultaneous with other appropriate medical treatments; comprehensive care—pain
and symptom management; communication; psychologic, emotional, and spiritual counseling; practical information;
palliative care teams often include chaplains, social workers, nurses, physicians, and pharmacists
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 | Spectrum of palliative care: day of diagnosis (patient asks about death and how long expected to live); course of illness
(treatment no longer possible; patient tires of treatment); day of death (mostly palliative, but curative treatments
may continue, eg, β-blockers for heart failure); after death (responsibilities to families in bereavement)
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| “Best care possible”: combines curative care and palliative care, focusing on quality of life
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| What families and patients want: palliation of symptoms; communication about illness and death; psychosocial
support
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| Frequent symptoms at end of life: dyspnea; pain (40% of patients had moderate-to-severe pain in last 3 days
of life, even though pain medication available); findings based on large study of patients in hospitals
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| Patient environment: in speaker’s hospital, “comfort care suites” look more like home; environment supports
plan of care and encourages family to be with patient
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| Improving communication with patients
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| Listen: ask open-ended question and allow patient 2 min to respond (on average, physicians interrupt after 18
sec); what to ask—“how have things been going for you at home?”; “what’s on your mind?”; “what’s worrying
you the most right now?”
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| Elicit values and goals of care: rigid guidelines (eg, advance directives specifying maximum hours on ventilator)
not helpful; what to say—“when you think about what lies ahead, what worries you most?”; “when you think
about the future, what do you hope for?”
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| Prognosis: avoid false hope; focus on realistic expectations; information—lack of explicit information allows
people to infer and have “wildly optimistic” expectations; of patients who undergo cardiac arrest in hospital,
only 14% discharged to home (patients assume percentage much higher); information influences decisions;
prognostic accuracy—appropriate to provide range (eg, hours-to-days, days-to-weeks, weeks-to-months); reflective
of uncertainty of prognosis yet provides useful information; importance—“we would all live our lives
differently if we knew we had only a year to live”
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| Identifying patients: to decide which patients to talk to about end-of-life issues, ask, “would I be surprised if this
person died in the next year?”
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| Discussing death: patients already thinking about death; what to say—“many patients with [this condition] tell
me they think about the possibility of dying; they have questions about [this]; how about you?”
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| Nonabandonment: patients want security of clinician’s presence; our presence at bedside important, even when
no curative treatment available
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| Hope: encourage hope by asking about it, eg, “what do you hope for?”
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| Growth and development at end of life: completing tasks—eg, saying goodbye to loved ones; closure to
relationhips—“forgive me”; “I forgive you”; “thank you”; “I love you”; “goodbye”; telling their story—we
live on in memory of others (eg, through video, audio recording, computers, writing, stories of physicians and
families)
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| Spirituality: related to issues of mortality; useful questions—“are you a religious or spiritual person?” (patients
may be religious and/or spiritual or neither)
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| Conclusion: death, as part of life, will come to us all; dying people have many distressing symptoms that need
treatment; people with terminal or otherwise serious illnesses want to discuss death, dying, and prognosis; we
have much to offer of ourselves (ie, not just our treatments, but our humanity) to dying patients
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| RATIONAL USE OF OPIOIDS IN PAIN MANAGEMENT —Christine A. Miaskowski, RN, PhD, Professor, Department
of Physiological Nursing, Program Leader for UCSF Comprehensive Cancer Care Center, Program in
Symptom Management and Palliative Care, University of California, San Francisco, School of Medicine
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| Introductory pearl: “take the word ‘narcotic’ out of your vocabulary; you don’t prescribe narcotics”; “opioid
analgesics” medical term; “narcotics” law enforcement term
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| Principles of pain management: ascertain cause of pain; prevent pain when able (treating acute, eg, postoperative,
pain reduces likelihood of developing chronic pain syndrome); manage chronic pain like other chronic
medical conditions; individualize dosing regimen (correct dose of medication equals dose that works); titrate
dose of analgesic medication to desired effect or until adverse effects intolerable; anticipate and treat adverse effects
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| Pharmacologic management: nonopioid analgesics; opioid analgesics; adjuvant analgesics or coanalgesics
(primarily used to treat neuropathic pain)
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| Nonopioid analgesics: most prescribed class of medications; useful for mild-to-moderate pain (1-4 on 0-10
scale); numerous choices; significant inter-individual variability in response to acetaminophen and nonsteroidal
anti-inflammatory drugs (NSAIDs); ceiling effect; narrow therapeutic dosing range; take-home message—if patient
does not benefit from NSAID, try another NSAID (from different class)
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| Principles of using opioids: combining opioid with nonopioid analgesic yields synergistic effect; efficacy maximized
when used around-the-clock; monitoring intensity of chronic pain—focus on function and pain relief, not
0-to-10 scale; ascertain adherence to analgesic regimen
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| Combination opioids and nonopioids: hydrocodone and acetaminophen (Vicodin), oxycodone and oxycodone
terephthalate (Percodan), oxycodone and acetaminophen (Percocet); good for moderate pain (4 to 5); usefulness
limited by ceiling dose of acetaminophen; note—evaluate patient’s use of over-the-counter
acetaminophen
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| Short-acting opioids: important concepts in pharmacokinetics include duration of analgesic effect and half-life
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| Morphine and hydromorphone (Dilaudid): commonly used short-acting agents for acute or breakthrough pain;
analgesic effect ≈4 hr; half-life 6 to 8 hr
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| Meperidine (Demerol): limited effectiveness; analgesic effect 2 hr; half-life 4 to 6 hr; first metabolite (normeperidine)
neurotoxic (half-life 15-30 hr); risk for seizures; neurotoxicity not reversed by naloxone (Narcan;
lowers seizure threshold); drug interactions—associated with serotonin syndrome when combined with fluoxetine
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| Propoxyphene (Darvon): synthetic opioid, similar to methadone; toxic metabolite (norpropoxyphene) produces
proarrhythmic effects; not appropriate for use in elderly
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| Relatively long-acting opioids: often used for cancer pain before other options available
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| Levorphanol (Levo-Dromoran): analgesic effect 6 to 8 hr (allows patient to sleep through night); half-life 12 to
16 hr
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| Methadone: acts on opioid receptor and 2 nonopioid receptors involved in chronic pain (acts as serotonin reuptake
inhibitor and N-methyl-D-aspartate [NMDA] antagonist); pharmacokinetics—analgesic effect 6 to 12
hr (dosed at 6-, 8-, or 12-hr intervals); half-life 15 to 60 hr; other benefits—inexpensive
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| Controlled-release opioids: controlled-release morphine; controlled-release oxycodone (OxyContin); opioid
contained within matrix; short-acting opioid used for breakthrough pain (10%-15% of around-the-clock dose q 2
hr); approved dosing intervals 8, 12, or 24 hr
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| Fentanyl transdermal system: Duragesic patch, now off patent; rate of release depends on surface area of
patch in contact with skin; pharmacokinetic considerations—requires 1 hr for onset of action and 17 to 40 hr to
achieve steady state; if switching from controlled-released drug to patch, administer ≈2 more doses of oral drug;
note—fever increases absorption; decreased peripheral circulation retards absorption
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| Oral: preferred route, except for patients with severe pain; slow onset of action (≥45 min)
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| Rectal: pharmacokinetics same as oral route; alternative to oral route
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| Transdermal: useful for patients unable to take oral medications
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| Intramuscular: not recommended; painful
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| Intravenous: rapid onset of action; for lipophilic drugs (eg, fentanyl), peak effect takes 1 to 5 min; for morphine
or hydromorphone, peak effect takes ≈15 min; titration achieves optimal pain control; adverse effects reversible
with naloxone
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| Adverse effects: mainly constipation, nausea and vomiting, and sedation; tolerance develops to all adverse effects,
except constipation
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| Nausea and vomiting: no antiemetic found superior to another
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| Sedation: most common at initiation of therapy; symptoms abate over few days at steady dose; exacerbated by
some comorbidities (eg, dementia) and medications; driving safety—systematic review of patients on long-term
opioid therapy found no increase in motor vehicle accidents; management of sedation—caffeine; methylphenidate
(morning and mid-day dosing only)
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| Respiratory depression: most serious adverse effect; tolerance develops quickly; relatively rare event; acute
toxicity—reversible with naloxone
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| During long-term opioid therapy: do not administer 2 ampules of naloxone; first—evaluate patient to determine
need to reverse respiratory depression; if not, reasonable to continue opioid; recommendation for reversing—
dilute 1 ampule of naloxone in 9 mL of saline; administer 0.5-mL bolus every 2 min to slowly reverse respiratory
depression; note that intravenous (IV) naloxone lasts 30 min (important for patients on patch or controlled-release
opioid)
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| Constipation: most common adverse effect, occurring in 40% to 60% of patients; tolerance does not develop;
new therapies expected in 3 to 5 yr; when prescribing opioid—add prescription for prophylactic bowel regimen;
recommendations—docusate (Colace) and senna (sennosides); lactulose; monitor patient—for constipation interfering
with analgesic regimen
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Educational Objectives
| The goal of this program is to educate the listener about end-of-life palliative care and use of opioids to manage
pain. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Define palliative care.
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| 2. Anticipate needs of patients near end of life.
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| 3. Improve communication with patients facing death.
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| 4. Manage therapy with opioid analgesics to control pain in patients at end of life.
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| 5. Avoid and limit adverse effects of opioid analgesics, including constipation.
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Discussed on This Program
Acetaminophen (several formulations and trade names)
Caffeine (several trade names)
Docusate sodium (dioctyl sodium sulfosuccinate; DSS) [Colace, Diocto, Phillips’ Liqui-Gels, others]
Fentanyl transdermal system [Duragesic-25, Duragesic-50, Duragesic-75, others]
Fluoxetine HCl [Prozac, Sarafem]
Hydrocodone bitartrate and acetaminophen [Co-Gesic Tablets, Lortab 5/500 Tablets, Vicodin Tablets, others]
Hydromorphone HCl [Dilaudid, Dilaudid-5, Dilaudid-HP, Palladone]
Lactulose [Cephulac, Constulose, Duphalac, others]
Levorphanol tartrate [Levo-Dromoran]
Meperidine HCl [Demerol]
Methadone HCl [Dolophine HCl, Methadone HCl Diskets, Methadone HCl Intensol, Methadose]
Methylphenidate HCl [Concerta, Ritalin, Ritalin LA, others]
Morphine sulfate (several trade names)
Naloxone HCl [Narcan]
Oxycodone HCl [ETH-Oxydose, OxyContin, Roxicodone, others]
Oxycodone HCl and acetaminophen [Percocet, Roxicet, Roxicet 5/100, Roxicet Oral Solution, Roxilox, Tylox
Capsules]
Oxycodone HCl and oxycodone terephthalate [Percodan, Percodan-Demi, Roxiprin]
Propoxyphene (dextropropoxyphene) [Darvon-N, Darvon Pulvules]
Sennosides [Black-Draught, Senexon, Senna-Gen, Senokot, Senokot, others]
Suggested Reading
Ahles TA, et al: A controlled trial of methods for managing pain in primary care patients with or without co-occurring
psychosocial problems. Ann Fam Med 4:341, 2006; Amabile CM, Bowman BJ: Overview of oral modified-release
opioid products for the management of chronic pain. Ann Pharmacother 40:1327; Block SD et al:
Learning from the dying. N Engl J Med 353:1313, 2005; Bolen J: DEA, administrative action statistics, and pain
management: It’s time to get real. Pain Med 7:358, 2006; Cherny NI: Sedation for the care of patients with advanced
cancer. Nat Clin Pract Oncol 3:492, 2006; Deitrick GE, et al: Palliative care and end-of-life care World
Wide Web resources for geriatrics. J Pain Palliat Care Pharmacother 20:47, 2006; Giordano J: Cassandra’s
curse: Interventional pain management, policy and preserving meaning against a market mentality. Pain Physician
9:167, 2006; Hallenbeck J: A Palliative Ethic of Care: Clinical Wisdom at Life’s End. Oncologist 11:527, 2006;
Hallenbeck J: Palliative care training for the generalist a luxury or a necessity? J Gen Intern Med 21:1005, 2006;
Mackenzie JW: Acute pain management for opioid dependent patients. Anaesthesia 61:907, 2006; Mercadante
S, et al: Safety and effectiveness of intravenous morphine for episodic breakthrough pain in patients receiving
transdermal buprenorphine. J Pain Symptom Manage 32:175, 2006; Pantilat SZ, et al: Evaluating the California
Hospital Initiative in Palliative Services. Arch Intern Med 166:227, 2006; Rhodin A: The rise of opiophobia. J
Pain Palliat Care Pharmacother 20:31, 2006; Wiffen PJ: Evidence-based pain management and palliative care. J
Pain Palliat Care Pharmacother 20:77, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant
financial relationship with the manufacturer or provider of any commercial product or service discussed. The following
has been disclosed: Dr. Miaskowski is a consultant for Cephalon Inc, Endo Pharmaceuticals, and PreCare.
Dr. Pantilat was recorded at 34th Annual Advances in Internal Medicine, June 19-23, 2006; Dr. Miaskowski was recorded
at Pain Management and End-of-Life Care, June 4-5, 2006; both meetings held in San Francisco, CA, and
sponsored by University of California, San Francisco, School of Medicine. The Audio-Digest Foundation thanks the
speakers and the sponsor for their cooperation in the production of this program.
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