The International Association of Hospice and Palliative Care Comprehensive Pain Assessment and Management Course, available free to members and accessible by video online, is intended for pharmaceutical, medical, and nursing professionals. This is an introduction to modules 4-6. An overview of the first 3 modules appeared in the July Newsletter.
By Alison Ramsey
IAHPC Newsletter Editor
The goal of opioid rotation is to improve patient outcomes, states palliative care pharmacist Dr. Ebtesam (Sammi) Ahmed at the beginning of the fourth session of IAHPC’s Comprehensive Pain Assessment & Management Course.
“It is done to minimize adverse responses, maximize efficiency, and improve function, including physical, psychosocial, and/or quality of life, like being able to get out of bed, go to work, reduce distress. […] Ask yourself, ‘Why am I switching this patient in particular?’”
One common reason to rotate opioids is when a patient’s pain does not respond to higher doses of a medication. Another is the medication’s unwanted side effects. Regardless of the reason, the first step is a proper assessment, she emphasizes.
In the session, Ahmed presents equianalgesic tables (one for methadone, and one for other analgesics) and the five-step conversion calculation process, reviews evidence-based guidelines for opioid rotation, and offers six cases that illustrate a variety of patient situations and treatments.
She discusses different types of breakthrough pain: spontaneous (happens without warning), incident predictable (e.g., when bandages are changed), incident unpredictable (e.g., when sneezing, coughing), and end-of-dose (pain recurs before the next scheduled dose).
“There are many clinical situations where opioid conversion is an appropriate intervention,” she concludes, but “follow-up is critical to patient success.”
This session, given by IAHPC Board Chair Dr. Lukas Radbruch, covers the most common side effects of opioids: nausea/vomiting, constipation, confusion, and sedation (including risk of falls). He counsels that, except for constipation, side effects are common but usually limited to the onset of opioid therapy, or when dosage is increased.
“Doctors will say about constipation, ‘It’s not the most urgent problem, is it?’” But nurses chided Lukas for sharing that view, telling him, “That’s something that a doctor would say.”
Constipation can cause patients significant pain and extreme distress.
“It’s rarely addressed by physicians,” he says, “but we should be more aware of the urgency of treatment.”
Treating symptoms by reducing opioid dosage “is not always optimal,” he says, noting that opioids are the best treatment for breathlessness (not to be confused with respiratory depression), and are not necessarily responsible for mental confusion, which can be multifactorial and traceable to other medications.
Treatment ladders provided for nausea/vomiting and constipation provide non-pharmaceutical and pharmaceutical solutions, including starting points, titration, and maximum dosages.
Side effects are described and assessed, diagnostic methods are presented, and treatments are described in detail.
Practical advice is sprinkled throughout, such as giving a wine-cooler-sized bucket to a patient who vomits copiously, as the small receptacles routinely used in health care are insufficient. Or showing a patient an acupressure point to ease nausea, which works for many and “gives patients back some control.”
Regarding opioid therapy in general, Radbruch reports that doctors in the US say that cancer patients have two problems: cancer and opioid dependency. However, “my experience is that patients are always quite happy when you can reduce their opioids” as it means that their pain has decreased. “Misuse and dependency do happen, but our experience is that it is pretty rare.”
Patients have described neuropathic pain as feeling like a bolt of lightning, or a red-hot poker; the patient feels more pain than the accompanying lesion, movement, or touch would suggest. Musculoskeletal pain can range from a dull ache to so severe that it is disabling.
“A large percentage of people have multiple pain types,” notes Radbruch.
“Always think of the bio-psycho-social origin of the patient’s pain,” he instructs. “Be clear about treatment goals, keep the assessment simple (don’t subject patients to long, arduous tests), and discuss both background pain and breakthrough pain.”
The session provides decision trees for breakthrough pain, bone/periosteal pain, and neuropathic pain, followed by a discussion of pain management co-analgesics: antidepressants, anticonvulsants, and steroids.
Examples and instructions are given. For instance, “My ladder for neuropathic pain starts with opioids; it responds to opioids better than nociceptive pain does.” If the pain persists, he counsels switching to an anti-depressant (his choice? amitriptyline) if time allows: it can take a few weeks to reach an effective dose. For bone metastases, “ibuprofen is my medicine of choice: NSAIDS (non-steroidal anti-inflammatory drugs) are the base treatment plus opioids for breakthrough pain, as patients often have pain with movement.”
“Some patients have said that when they lie in bed, they are pain-free, and when they move it hurts like hell. With higher doses, then can move—but fall asleep as soon as they lie down,” says Radbruch. Patients, he adds, should be given the choice. “You have to ask: Which do you prefer?” Their preference is often clear.
Thanks to donations from current and previous board members, the IAHPC was able to provide access to 31 individuals from Middle and Low income countries.