Pain at the end of life
From IDWiki
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)
