TREATING CHRONIC PAIN
in
SERIOUSLY ILL PATIENTS
Jack McNulty,MD, FACP, FAAHPM
President, Palliative Care Institute of
Southeast Louisiana
jackmcn12@bellsouth.net
985-373-1690 fax 985 892-7891
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
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
Barriers to Treating Chronic Pain
•
•
•
•
•
Education
Experience
Fear of Regulators
Fear of Addicting Patients
Fear of Opioid use in the Dying
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
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.
Addiction
• The problem in addiction and with
substance abusers is not with the opioid,
alcohol,etc .It lies within the abuser’s 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.
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.
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.
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.
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 2010;137:674-691
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: 2012;185:435-452
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
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.
Changing from Acute Pain
to 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
Acute and Chronic Pain
Brookoff,D:1) Chronic Pain: A New Disease?: Hosp Pract: 35(6); Minneapolis,MN; 45-59
Consequences of
N-Methyl-D-Aspartate Receptor
Activation
•
•
•
•
•
Windup
Neural Remodeling
Activation of Neurokinin-1 Receptors
Afferent becomes Efferent
Neurogenic Inflammation
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
4/13/2015
18
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
4/13/2015
19
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
4/13/2015
20
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 thalamus…pain is untreatable
• Pain is no longer confined to the original site in
some patients
• Detected in fibromyalgia in lab studies
4/13/2015
21
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
4/13/2015
22
Neurogenic Inflammation
• A tissue reaction caused by Substance P and
nerve growth factor, affecting synovia and
other connective tissue.
• Doesn’t depend on granulocytes or
lymphocytes
• Substance P causes de-granulation of mast
cells, releases bradykinin, nitric acid.
4/13/2015
23
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
4/13/2015
24
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
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.
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
WHO 3-step
3 severe
Ladder
Morphine
2 moderate
Hydromorphone
Methadone
A/Codeine
Levorphanol
A/Hydrocodone
Fentanyl
A/Oxycodone
Oxycodone
ASA
A/Dihydrocodeine
± Adjuvants
Acetaminophen
Tramadol
NSAIDs
± Adjuvants
1 mild
± Adjuvants
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.
4/13/2015
29
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
4/13/2015
30
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).
4/13/2015
31
Duragesic (Fentanyl)
• Duragesic patch: use care in opioid- naïve
patient, only after pain controlled by shortacting 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
4/13/2015
32
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.
4/13/2015
33
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)
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.
4/13/2015
35
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,liquid;iv; 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.
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 )
Adjuvants for Neuropathic Pain
• ANTICONVULSANTS:
• Gabapentin, Lyrica, Valproic Acid, Lamotrigine,
Tegretol
TRICYCLIC ANTIDEPRESSANTS:
Amytryptiline
Imipramine
Nortryptiline
Desipramine
OTHERS:
Duloxetine ( Cymbalta )
Lidocaine
Adjuvants for Nociceptive Pain
• Tricyclic Antidepressants (desipramine or
nortryptiline preferred)
• NSAIDS
• Corticosteroids ( dexamethasone preferred)
• Metoclopramide (for visceral pain)
WORKSHOP:
CONVERTING OPIOIDS
Palliative Care Institute of Southeast Louisiana
752 N. Columbia St., Covington, LA 70433
John P. “Jack “ McNulty, MD, FACP,FAAHPM
jackmcn12@bellsouth.net 985-373-1690
George Muller, R.Ph, Consultant,
Compounding Pharmacist
george@mullercbs.com
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.
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
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
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.
CONVERTING TREATMENT: from oral
MORPHINE to oral LEVORPHANOL
Morphine (MS)/24 h to Levorphanol (LEV)/24 h
•
•
•
•
•
MS < 100 mg
12:1 (12 mg MS:1 mg LEV)
MS 101-300 mg 15:1 (15 mg MS:1 mg LEV )
MS 301-600 mg 20:1 (20 mg MS: 1 mg LEV )
MS 601-800 mg 25:1 (25 mg MS: 1 mg LEV )
MS 801-1000 mg No data
• MS > 1000 mg
No data
MD Anderson Ratios to Convert
Oral Morphine to Oral
Methadone:
•
•
•
•
•
•
•
Morphine Equivalent Daily Dose (oral):
<30mg: ratio MS to Methadone = 2:1
30-99 : “ “
“
= 4:1
100-299: “ “
“
= 8:1
300-499: “
“
“
= 12:1
500-999: “ “
“
= 15:1
>1000 : “ “
“
= 20:1
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.
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 chart:60mg hydrocodone = 40mg MS
+ Oxycocone 60mg = 60mg MS
• MS equivalent= 100 mg/ 24hr.
• Convert to Fentanyl: next slide
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.
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
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.
4a:Chronic 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:
4b: Convert to Levorphanol
• From conversion chart, the ratio of
morphine to levorphanol = 12:1 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.
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 Med:2013,16 ( June)
Levorphanol or Methadone?
• Levorphanol advantages: No stigma, no
ECG prolongation of QTc, predictable halflife, 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!
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:
5b: Converting Morphineequivalent. to Oxycodone
•
•
•
•
From chart,1mg oxycodone=1mg 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.
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
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 8:1.
• 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.
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
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: 20:1
• 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
“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)
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 nonmalignant. Mentor is helpful with complex case.
• Palliative Care team can help relieve complex
chronic pain in seriously ill suffering patients.
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.
Palliative Care at Home
with or without Hospice
for 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.
Alternative Rx for Case 1
• Don’t 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
Case 2
Lung 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.
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.
Case 2 near- terminal
• Dilaudid PCA not controlling pain; 2 mg/hr
plus 20mg demand, for total 68mg/24hr.
• Morphine equivalent=68 x20=1,360 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,
Case 3
End-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.
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.
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).
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 MS:Lev is 20:1 in this case, so Lev. dose
is 24 mg/ day, or 6mg q 6 hr. Pain reduced, with
no adverse effects