Pain at the end of life: Difference between revisions

Latest revision as of 11:35, 29 July 2020

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)

@@ Line 1: / Line 1: @@
+== 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 (&lt;7-10 days), low is best
+*If naive (&lt;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
-{|
+*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]]