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Palliative Care Summer Institute
Basic and AdvancedPain Management for
CliniciansMargaret A. Jacobson, MD
Shaun Sullivan, MDMedical Directors, Whatcom Hospice
Palliative Care Summer Institute
Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions
Relieving Pain in America: Institute of Medicine (2011)
Palliative Care Summer Institute
2010 Washington State Rules regarding chronic pain management DO NOT APPLY to
Chronic cancer pain Acute pain caused by an injury or a surgical
procedure Palliative, hospice, and other end-of-life care
Pain Management for whom?
Palliative Care Summer Institute
Ongoing Individualized Documented
“Tell me about your pain….”
Pain Assessment: The cornerstone of optimal pain management
Palliative Care Summer Institute
OPQRST “Tell me about your pain”
Onset Provoking, Palliating Quality Region/ Radiation Severity Treatment Understanding
Palliative Care Summer Institute
Analgesics should be given “by mouth, by the clock, by the ladder, and for the
individual”(World Health Organization)
Principles of Analgesia
Palliative Care Summer Institute
It is not necessary to traverse each step of the ladder sequentially
For mild pain (1-3) start at step 1 For moderate pain (4-6) start at step 2 For severe pain (7-10) start at step 3
…By the WHO ladder
Palliative Care Summer Institute
Safe Reliable Effective for all types of pain Have multiple routes of administration Are easily titrated
Opioids: Mainstay of treatment of moderate-severe pain in advanced illness
Palliative Care Summer Institute
Opioids follow first-order kinetics and pharmacologically behave similarly Peak plasma concentration (C max)
60-90 minutes after oral administration 5-10 minutes after IV administration
Opioids are eliminated from the body in a direct and predictable way, irrespective of the dose The liver conjugates them The kidney excretes 90-95% of the metabolites Their metabolic pathways do not become saturated
Each opioid metabolite has a half life that depends on its rate of renal clearance When renal clearance is normal, codeine, hydrocodone, hydromorphone,
morphine, and their metabolites all have effective half lives of approximately 3-4 hours
When dosed repeatedly, their plasma concentrations approach a steady state after about 4-5 half lives (1 day)
Opioid Pharmacology
Palliative Care Summer Institute
Routine dosing: Dosing interval is 1 half life
4 hours Bolus/breakthrough dosing: dosing interval
is time to peak effect
1 hour orally, 10 minutes IV Steady state: achieved after 4-5 half lives
1 day
Opioid pharmacology simplified
Palliative Care Summer Institute
Constant pain needs constant control Start an opioid naïve patient with a short acting opioid, and
dose every 4 hours, NOT prn The best possible pain control for the dose will be achieved
within a day (once steady-state is reached) Provide the patient access to prn doses of the SAME medication
that can be used should breakthrough pain occur Every hour for oral opioids Every 10 minutes for IV opioids Do not use extended release opioids for rescue dosing Longer intervals between breakthrough dosing only
prolong a patients pain unnecessarily
Opioid basics
Palliative Care Summer Institute
Renal considerations Opioids and their metabolites are primarily excreted renally Morphine has 2 principal metabolites: 3 and 6 glucuronide Morphine 6 glucuronide is active and has a longer half life
than the parent drug With impaired renal clearance, excessive accumulation of
the drug must be avoided by either Increasing the dosing interval Decreasing the dose
With oliguria or anuria, stop routine dosing and administer only as needed
Renal Failure considerations
Palliative Care Summer Institute
Opioid metabolism is not as sensitive to hepatic compromise
With severe hepatic impairment Increase the dosing interval Decrease the dose
Liver failure considerations
Palliative Care Summer Institute
DRUG IV PO
Morphine 10mg 30mg
Codeine 200 mg
Hydrocodone 30 mg
Oxycodone 20 mg
Hydromorphone 1.5 mg 7.5 mg
Fentanyl 0.1 mg
Equianalgesic conversions
Important insights: 1. Oral morphine and oral hydrocodone are equally potent2. Oral oxycodone is more potent than oral morphine3. Hydromorphone is 4-7 X more potent than morphine