Opioid Stewardship in Palliative Care and End of Life

Care

Stephanie Abel, PharmD, BCPS – UK HealthCare

Katrina Nickels, MD – Bluegrass Care Navigators

Disclosure of Conflicts of

Interest

– Katrina Nickels, MD and Stephanie Abel,

PharmD, BCPS have no real or apparent financial

relationships to report.

Objectives

– Distinguish between Pain Management,

Palliative Care, and End of Life care

– Discuss general best practices for

responsible opioid prescribing in

palliative care patients

Palliative

Care (PC)

Palliative Care

Interdisciplinary Model

– Spiritual

– Social Work

– Financial, community resources

– Family dynamics

– Anticipatory Education

– Care Navigation

– Advance Care Planning

– Multimodal pain management

– Acute Symptom Distress management

– End of Life Pain

End of life (EOL)

Definition from medical perspective

Hospice qualification

Prognosis

Expectations

Pain at the EOL

– Prevalence in literature ~50% - 75%

– 17 - 35% of patients experience severe or intolerable pain

in their last week of life

– Myths/misconceptions

– Palliative and hospice providers use opioids in everyone

– Palliative care clinicians rely primarily on opioids for analgesia

– Risks of opioid misuse aren’t relevant in palliative and hospice

– Opioids at EOL hasten death

– Principle of Double Effect (PDE)

Pain Manag Nurs. 2018;19(1):3-7.

BMC Palliat Care. 2020;19(1):60.

Opioids -

Indications

Medication for Opioid Use Disorder

Pain

Dyspnea Cough

Opioid Indications

KY Regulatory Environment

– KY House Bill 1

– Goal was to decrease opioid prescribing

– KAR 9:270

– Amended May 12, 2020 to allow exceptions for inpatient care,

hospice and palliative care, and cancer pain in active treatment

Palliative Care and Pain

Management

– Chronic pain pharmacologic management is the same approach, regardless of malignant or non-malignant (Multimodal analgesia, Functional Pain Goals)

– Palliative Care Interdisciplinary Team model may enhance attention to the spiritual, social, and emotional aspects of pain

Total Pain

Physical

• Caused by treatment

• Caused by illness

• Concomitant disease

Psychological

• Anxiety

• Depression

• Fear of suffering

Social

• Financial

• Loss of job

• Loss of role in family &/or social circles

• Worries about future

• Fertility & parenthood issues

Spiritual

• Anger

• Loss of faith

• Finding purpose

Ong C-K, Forbes D. BMJ. 2005;331(7516):576-576.

Pain Management Approach in PC

Marco Cascella, MD. The revised WHO analgesic ladder. StatPearls Publishing Jan 2020.

WHO

Analgesic

Ladder

Evolution

Multimodal

Approach

Optimal Pharmacotherapy

Psychological

Education

Physical Medicine /

RehabInterventional

Non-pharmacologic

Opioids and Cancer

A Disease State Overview of the Importance of

Opioid Stewardship in Palliative Pain

Management

Opioid Use and Cancer Collide in Kentucky

– 32 Kentucky counties are in

the 90th or higher

percentile of opioid

prescribing per capita

– 79 Kentucky counties are in

the 90th or higher

percentile of cancer

incidence per capita

– 26 Kentucky counties are in

both

Occurrence of OUD in

Patients with Cancer

– Not well evaluated/documented

– Same risk as general population?

– General incidence of any SUD is ~9%

– Cancer pain is NOT protective of misuse or OUD development

– Additional risk?

– Chemical coping

– ↑ prevalence of depression & anxiety – during and after treatment

– Link with SUD

– Regular abuse of some substances ↑ cancer risk

Paice JA. Cancer 2018;124:2491-7.Lee JS, et al. J Clin Oncol 2017;35:4042-9.

Patients with Cancer Represent an Ignored Need

Loren AW. NEJM 2018;379:2485-7.Kata V, et al. Curr Opin Support Palliat Care 2018;124-30.

Huang R, et al. J Clin Oncol 2019;37:1742-52.Sutradhar R, et al. Cancer 2017;123:4286-93.

Peppin J. J Pain Res 2016;9:23-4.

Cancer

Related

Pain

– 70% experience pain during disease

course

– 33% develop long-term pain

– Increased survival

– Risk factors for chronic pain

– Opioids historic cornerstone

– Best for acute cancer pain

– NOT foundation for managing chronic (late) cancer

pain or neuropathic pain

– Adverse effects with long-term use

– Most experience with non-opioid modalities

based on non-malignant dataVan den Beuken-van Everdingen MH et al. J Pain Symptom Manage. 2016;51:1070-1090.Green CR et al. Cancer. 2011;117:1994-2003.

Chronic

Pain

Syndromes

Associated

with

Cancer

Treatment

Chemotherapy• Bony complications

• Avascular necrosis

• Compression fractures

• CTS

• CIPN

• Raynaud’s

Hormonal Therapy• Arthralgias

• Dyspareunia

• Gynecomastia

• Myalgias

• Compression fractures

(osteoporosis related)

Radiation• Chest wall syndrome

• Cystitis

• Enteritis

• Proctitis

• Fistula formation

• Lymphedema

• Myelopathy

• Osteoporosis

• Osteoradionecrosis

• Peripheral

mononeuropathies

• Plexopathies

Immunotherapy• Inflammatory arthritis

• Myositis

• Peripheral neuropathy

• Polymyalgia-like

syndrome

HSCT/GVHD• Arthralgias/myalgias

• Dyspareunia, vaginal pain

• Dysuria

• Eye pain, Oral pain

• Paresthesias

• Scleroderma-like skin

changes

Surgery• Lymphedema

• Phantom pain

• Postmastectomy pain

• Post radical neck

dissection

• Post-surgery pelvic

floor pain

• Post-thoracotomy pain

• Frozen shoulder

• Extremity pain

Adapted from Table 1: Oncology (Williston Park). 32(8):386-90, 403.

New Challenges: Adverse Effects of

Long-Term Opioid Use• Constipation

• Mental clouding

• Pyrosis, bloating, nausea

Persistent, Common AE

• Fatigue

• Infertility

• Osteopenia/-porosis

• Decreased libido

• Reduced/absent menses

Endocrinopathies

• Dysimmune effects: enhanced sensitivity to viral/bacterial insults

• Tumor proliferation

Immune effects

• Myoclonus

• Mental status changes (clouding, mood effects, memory problems, balance)

• Opioid Induced Hyperalgesia

Neurotoxicity

• New & worsening Obstructive Sleep Apnea

Sleep-disordered breathing

• Withdrawal

Physiological dependence, tolerance

• Misuse

• Abuse

• OUD

• Depression

Psychological

1)Eur J Pain 2010; 14:1014-20; 2)Anesthesiology 2012;116:940-5; 2)J Clin Endocrinol Metab 2000; 85: 2215-22.; 3)Pain Physician 14:145-61, 2011; 4)Curr Pharm Des: 18:6034-42, 2012

What Risks are We Trying to Mitigate?

– Opioid-related death

– Often unintentional

– Patient, family, friends, society

– Opioid Use Disorder

– Impact on treatment

– Delays, harm, suffering

– Impact to access for patients who need opioids

Safe Opioid Use Considerations in

Patients with Cancer/Chronic Disease

– Tolerance

– Challenges of acute pain management in opioid tolerant

– Opioid induced hyperalgesia

– Drug interactions

– Opioid dose conversions

– Fentanyl patches

– Survivorship and tapering

– Financial/psychosocial distress

– Disease treatment in relapsed OUD

– Pain management in patients on MOUD

Universal

Precautions

for Opioid

Prescribing

– National/General

– Centers for Disease Control and Prevention

– Federation of State Medical Boards

– Oncology

– National Comprehensive Cancer Network

– American Society of Clinical Oncology

– Palliative/Hospice

– Center to Advance Palliative Care

– American Academy of Hospice and

Palliative Medicine

Adapted from Tables 5 & 6: Journal of Clinical Oncology 2016 34:27, 3325-3345.

• Exam and review of medical records

• Review PDMP

• Conduct initial UDS

Assess pain & risk of misuse

• Stratify risk of diversion and abuseDecide if opioids

appropriate• Optimize non-opioids and non-pharm analgesic modalities

• Multimodal pain approach

• Obtain treatment for psychiatric illness (includes anxiety, depression, sleep disorders, PTSD, etc.)

Minimize risk

• Evaluate effectiveness (5 A’s)

• Review and treat AE

• Monitor adherenceMonitor

• Assess for indicators of uncontrolled pain, misuse, abuse, or diversion

• Intervene – prescribe small amounts at shorter intervals, pill counts, more frequent UDS

• Consult psych/addiction specialists

Respond to aberrant behaviors

Universal Precautions – Opioid Rx

Importance of Expectation

Setting

Healthcare

Expectations

Predicted Ideal

Normative Unformed

Bialosky JE, et al. Phys Ther. 2010;90(9):1345-55.

Setting Pain

Goals

Keltner JR, et al. J Neurosci 2006;26(16):4437-43.Apfelbaum JL, et al. Anesth Analg 2003;97:534-40.

Function

Barriers

Tools

SMART Goal Setting

Monitoring and Addiction

Support

– Set expectations on best practices for monitoring/responsibility

– Standard of care

– Enhances care transitions

– Treat and coordinate care if issues arise (addiction medicine, shift

in treatment plan with safety and QOL in mind)

– Recognize that some patients have severe, complex pain & OUD.

Treatment of both improves outcomes for both disease states.

Impact of

Substance

Use or

OUD

Toward

End of Life

– Health care service access

– Additional health problems

– May have complex social situations

– Fear of being judged or stigmatized

– Difficult symptom management

– Organ dysfunction

– Drug interactions

– Tolerance

– Hyperalgesia

– Greater risk of adverse effects

“Caring for someone with substance use problems at end of life” Marie Curie Website. Available at: https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/equality-diversity/people-with-substance-use. Accessed 9/15/2020.

Stigma

and Bias

– Stigma = label + stereotype

– Bias

– Explicit = conscious

– Implicit = subconscious

– Implicit bias in healthcare professionals

– Significant relationship between implicit bias and quality of

care

– Word selection matters

– Negative explicit bias: “clean”, “dirty”, “medication-assisted

treatment”, “medication-assisted treatment”, “untreated”,

and “alcoholic”, “substance abuser”, “opioid addict”

– More positive explicit bias: “person with a substance use

disorder” and “person with an opioid use disorder”,

“recurrence of use”, “pharmacotherapy”, “medication-

assisted recovery”, “long-term recovery”Ashford RD, et al. Drug Alcohol Depend. 2018;189:131-138.

Kelly JF, et al. Int J Drug Policy. 2010;21(3):202-207.

FitzGerald C, Hurst S. BMC Med Ethics. 2017;18(1):19.

Bias and Levels of Compassion

Disengagement

• Disconnected

• Negative reactions for patient and provider

• Under-prescribing of opioids

Reactive compassion

• Knee jerk compassion

• Perceived as positive by patient and provider

• Over-prescribing of opioids

Conscious compassion

• Mindful compassion

• Perceived as positive by patient and provider

• “Goldilocks” prescribing –prescribing opioids is just right

Putting It Into Practice

Case Discussion

Baptist Palliative Clinic Algorithm

Establishing Care

Intake

• ORT-OUD/ COMM

• UDS

• Review PDMP

• Review medical records

Set Expectations

• Treatment agreement

• Informed consent

• Functional goals

Education

• Safe opioid disposal

• Naloxone

• Opioid safety

ORT= Opioid Risk Tool, COMM = Current Opioid Misuse Measure, UDS/UDT= Urine Drug Screen or Test, PDMP = Prescription Drug Monitoring Program

General Follow Up – All

Patients

Follow up within 1 month if prescribed a controlled medication

Medication counts and PDMP on every visit

For chronic opioid use, review COMM annually

Follow algorithm for frequency of visits and UDT based on ORT/COMM

Follow Up – Patients with History of

Substance Use Disorder(s)

– All general follow up PLUS

– Addiction clinic referral (if not already established)

– Follow-up visit schedule (initial – progression dependent upon aberrant behaviors and UDT results)

– Weekly x 4 weeks then

– Every other week x 2 then

– Monthly thereafter

Case

– 59yo with new inpatient diagnosis of metastatic pancreatic cancer to liver.

– Chronic low back pain on chronic oxycodone 10mg q6h and Gabapentin 800mg 4xdaily

– Started on Fentanyl 75mcg patch with oxycodone 10-20mg q6h PRN

– First outpatient f/u – pt taking all doses oxycodone, reporting use 2 tabs every 4 hours

– 1/2ppd tobacco smoking, 12 beers daily prior to hospitalization, social cannabis currently, remote

(>20yrs ago) occasional cocaine use. Adult child in long-term recovery for polysubstance use

– 1 week f/u: Increased Fentanyl patch, added quetiapine and duloxetine, referred to Behavioral

Health and Interventional Pain

– 1 week f/u: Overuse oxycodone, counseled re: anticipatory pain and anxiety, increased quetiapine,

wife agreed to manage medications

– 1 week f/u: No overuse, pt and wife saw Behavioral Health

– 2 week f/u x2: No overuse. Requested Chantix, down to 1 beer in 2 weeks.

Palliative Care and

Opioid Stewardship

Symptom indication, goals, prognosis, and setting Clarify

Implicit biasRecognize

Universal precautions with opioid prescribingApply

Structure, treatment, & set boundaries when misuse occursSupport

Questions ?