Pain at the end of life
From IDWiki
Management
General approach
- Assess the symptom
- Reverse what you can
- Treat what remains
- Monitor frequently
Opioids
- Codeine: ~10% lack enzyme to convert to morphine
- Morphine: has toxic products that cause delirium that are renally cleared
- See opioids for more information, including an equianalgesia chart
Starting Dose
- If naive (<7-10 days), low is best
- Morphine 2.5-5.0mg po q4h
- Hydromorphone 0.5-1.0mg po q4h
Breakthrough
- 10% of TDD (i.e. 1/2 of the q4h dose) q1h prn
- Peak effectiveness reached around 1h after oral dose
Titration
- When stable, add breakthrough doses to standing
- Don't add it if used for incident pain (e.g. associated with specific activities)
Rotation
- Opioid rotation may decrease some side effects, including hyperanalgesia and delirium
- Use the equianalgesia chart to convert to and from oral morphine equivalents
- In general, decrease the total daily dose by about 20% when rotating to a new opioid
Management of side effects
- Constipation
- Drowsiness:
- Decrease dose if can't keep eyes open or can't complete a conversation
- Nausea
- Add dimenhydrinate unless already on an antiemetic
- Should settle within a week
- Delirium
- Opioid rotation
- Haloperidol (standing, if necessary)
