Pain at the end of life - Revision history

Aidan at 15:35, 29 July 2020

2020-07-29T15:35:52Z

← Older revision		Revision as of 15:35, 29 July 2020
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			== Management ==
	Including use of opioids and other medications

	== General ~~Approach~~ ==		===General approach===

	* Assess the symptom		*Assess the symptom
	* Reverse what you can		*Reverse what you can
	* Treat what remains		*Treat what remains
	* Monitor frequently		*Monitor frequently

	== Opioids ==		===Opioids===

	* Codeine (~10% lack enzyme to convert to morphine)		*[[Codeine]]: ~10% lack enzyme to convert to morphine
	* Morphine (has toxic products that cause delirium that are renally cleared)		*[[Morphine]]: has toxic products that cause delirium that are renally cleared
			*See [[opioids]] for more information, including an equianalgesia chart
	* Oxycodone
	** Percocet (5mg oxycodone, 325mg acetaminophen)
	* Hydromorphone
	* Fentanyl
	* Methadone

	== Starting Dose ==		====Starting Dose====

	* If naive (<7-10 days), low is best		*If naive (<7-10 days), low is best
	** Morphine 2.5-5.0mg po q4h		**[[Morphine]] 2.5-5.0mg po q4h
	** Hydromorphone 0.5-1.0mg po q4h		**[[Hydromorphone]] 0.5-1.0mg po q4h

	== Breakthrough ==		====Breakthrough====

	* 10% of TDD (i.e. 1/2 of the q4h dose) q1h prn		*10% of TDD (i.e. 1/2 of the q4h dose) q1h prn
	* Peak effectiveness reached around 1h after oral dose		*Peak effectiveness reached around 1h after oral dose

			====Titration====
	== Opioid Equivalence Chart ==

		⚫	*When stable, add breakthrough doses to standing
	{\| class="wikitable"
		⚫	*Don't add it if used for incident pain (e.g. associated with specific activities)
	! Opioid
	!align="center"\| PO dose (mg)
	!align="center"\| SC/IV dose (mg)
	\|-
	\| Codeine
	\|align="center"\| 100
	\|align="center"\| —
	\|-
	\| Morphine
	\|align="center"\| 10
	\|align="center"\| 5
	\|-
	\| Oxycodone
	\|align="center"\| 5
	\|align="center"\| —
	\|-
	\| Hydromorphone
	\|align="center"\| 2
	\|align="center"\| 1
	\|-
	\| Fentanyl
	\|align="center"\|
	\|align="center"\|
	\|}

	== ~~Titration~~ ==		==== Rotation ====

			* Opioid rotation may decrease some side effects, including hyperanalgesia and delirium
⚫	* When stable, add breakthrough doses to standing
			* Use the [[Opioids\|equianalgesia chart]] to convert to and from oral morphine equivalents
⚫	* Don't add it if used for incident pain (e.g. associated with specific activities)
			* In general, decrease the total daily dose by about 20% when rotating to a new opioid

			====Management of side effects====
	== Side Effects ==

	* Constipation		*[[Constipation]]
	* Drowsiness		*Drowsiness:
	** Decrease dose if can't keep eyes open or can't complete a conversation		**Decrease dose if can't keep eyes open or can't complete a conversation
	* Nausea		*[[Nausea]]
	** Add ~~Gravol~~ unless already on an antiemetic		**Add [[dimenhydrinate]] unless already on an antiemetic
	** Should settle within a week		**Should settle within a week
	* Delirium		*[[Delirium]]
	** Opioid rotation		**Opioid rotation
	** Haloperidol (standing, if necessary)		**[[Haloperidol]] (standing, if necessary)

	[[Category:Palliative care]]		[[Category:Palliative care]]

Aidan: /* Opioid Equivalence Chart */

2020-07-17T13:20:53Z

Opioid Equivalence Chart

← Older revision		Revision as of 13:20, 17 July 2020
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	== Opioid Equivalence Chart ==		== Opioid Equivalence Chart ==

			{\| class="wikitable"
	{\|
	! Opioid		! Opioid
	!align="center"\| PO dose (mg)		!align="center"\| PO dose (mg)

Maintenance script: Imported from text file

2020-07-04T01:17:48Z

Imported from text file

New page

Including use of opioids and other medications

== 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)
* Oxycodone
** Percocet (5mg oxycodone, 325mg acetaminophen)
* Hydromorphone
* Fentanyl
* Methadone

== 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

== Opioid Equivalence Chart ==

{|
! Opioid
!align="center"| PO dose (mg)
!align="center"| SC/IV dose (mg)
|-
| Codeine
|align="center"| 100
|align="center"| —
|-
| Morphine
|align="center"| 10
|align="center"| 5
|-
| Oxycodone
|align="center"| 5
|align="center"| —
|-
| Hydromorphone
|align="center"| 2
|align="center"| 1
|-
| Fentanyl
|align="center"|
|align="center"|
|}

== Titration ==

* When stable, add breakthrough doses to standing
* Don't add it if used for incident pain (e.g. associated with specific activities)

== Side Effects ==

* Constipation
* Drowsiness
** Decrease dose if can't keep eyes open or can't complete a conversation
* Nausea
** Add Gravol unless already on an antiemetic
** Should settle within a week
* Delirium
** Opioid rotation
** Haloperidol (standing, if necessary)

[[Category:Palliative care]]