Pain at the end of life

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	PO dose (mg)	SC/IV dose (mg)
Codeine	100	—
Morphine	10	5
Oxycodone	5	—
Hydromorphone	2	1
Fentanyl

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)