IC6 Supportive and Palliative Care (Opioids use) Flashcards
(42 cards)
1
Q
Do we have to follow the pain ladder strictly?
A
No, it is just a guide
2
Q
Where do opioids come from?
A
Poppy plant
3
Q
What are some examples of natural, semi-synthetic and synthetic opioids?
A
Natural (opiates) — heroin, morphine, codeine
Semi-synthetic — hydromorphone, oxycodone, oxymorohone, hydrocodone
Synthetic — tramadol, fentanyl
4
Q
Which is a controlled drug — morphine syrup or oxycodone syrup?
A
Oxycodone syrup
5
Q
What do you have to look out for when giving morphine?
What are the side effects of morphine?
A
- Active morphine-6-glucuronide is renally eliminated
- For dying patients, they don’t die of cancer but end organ damage becos the cancer would have infiltrated the organs brain, liver, kidneys, so kidney failure is common.
E.g. multiple myeloma → hallmark signs is renal impairment
Thus if give morphine to these patients, would cause respiratory depression, extreme somnolence since it is accumulated in the body - Came from the greek word morpheus (god of dreams/sleep)
6
Q
Do we give short active or long acting opioids for chronic pain?
Scheduled dose or PRN?
A
- Short acting → Long Acting
- Chronic pain: scheduled doses (long term) superior to prn doses
- Add 50% to 100% of prn usage to around the clock scheduled doses, remember to institute plan to taper down when appropriate
Individualise the dosing - Rescue prn doses = 10% - 20% daily opioid requirements
7
Q
Is the conversion from 1 opioids to another bidirectional?
A
No
8
Q
If Mr TP is a 36 year old osteosarcoma patient with persistent bone pain. Patient says it is well controlled on current regimen. Taking:
- morphine controlled release 60mg PO TDS
- morphine syrup 10mg PO q4hrly PRN pain, avg 1-2 doses per day
Latest labs showed some new renal dysfunction. Need to recommend to switch to oxycodone. What is the dose and how to dosing instructions?
A
- Figure out the total baseline and total PRN in terms of morphine
- then convert it to oxycodone based on the ratio 3g.
- 30mg of morphine is = to 15-20mg of oxycodone
- There is 10mg oxycodone tablet in sg so we convert to 30-40mg tabs 3-4x a day, this is for baseline.
PO Oxycodone 30-40mg tablets TDS/QDS - PRN previously on syrup so gonna use the oxycodone syrup, so convert to 5-10mL q4hrs oxycodone syrup (the dosing for the PRN must follow the dosing instructions not what the patient is taking)
PO Oxycodone syrup 5-10mL q4hrly PRN
9
Q
Oxycodone is similar to which other opioid?
A
Morphine
10
Q
How many times is fentanyl stronger than heroin and morphine?
Is the half life short or long for IV fentanyl?
A
- 50x stronger than heroin
- 100x stronger than morphine
-
Very short half life
Use IV fentanyl a lot in ICU to sedate people, since it has fast onset and offset
11
Q
What are the 2 common ratios we use when converting morphine to fentanyl?
A
- 2mg/day PO morphine = 1mcg/hr fentanyl patch OD
- 3.6mg PO morphine ≈ 1mcg/hr fentanyl patch (90/25)
12
Q
Before starting patients on fentanyl patches, what should we ensure the patient has?
If patient does not have __, then what can we do if die die need to start fentanyl patch?
A
Opioid tolerance
- According to FDA, it means someone who can tolerate 60mg of oral morphine or equivalent per day
- Sometimes patient are not on that, prof dispense fentanyl patches in NUH where patient is only on morphine syrup, and they cant swallow, so want to start fentanyl patch, start with the smallest dose patch and use half a patch. Smallest dose patch is 12.5mcg/hr, so half is 6.25mcg/hr, so that’s about 15mg of oral morphine/day, and take 5mL of morphine per day so should be equivalent?
- But the problem is becos fentanyl is so potent, giving an equal analgesic dose, that’s not the full pic, equal analgesia does not mean equal side effects, they could stop breathing.
- So need to mention to the patient, becos can’t really change the minds of the dr. so want to see how to bring patient up to opioid tolerance first before changing to fentanyl patch but then they say no…
- So warn patient, say that when on this patch be around people that can monitor you, if you nodding off and breathing slowing, take that patch off since it might be overdosing.
- Is giving the smallest dose patch ok?
- They came up with the 60mg of morphine/day becos the smallest dose of fentanyl was 25mcg/hr
- But now with the smaller doses, is it safe? In practice it is done, but need to make sure that patient understand that it’s the same
13
Q
How is the absorption like for fentanyl patches?
What to counsel the patient on when using the fentanyl patches?
What is the onset of effect for fentanyl patches?
A
- Absorption could be erratic, heat can increase absorption
- Don’t go out under the hot sun
- Fever?
- IV fentanyl has a very fast onset, but for fentanyl patch, it has to be absorbed into your skin first and then into your subcutaneous tissues, which acts like a depot before entering into your bloodstream. All these take time before getting to a steady state, so will need to wait to get the analgesic effect but also steady state of side effects, so need to monitor the patient.
- Onset slow → steady state slower
-
Q72hours for most patients
Some rx will say change every 48hrs, should be every 3 days, but some patients have a wearing off effect so must back it up with some PRN (short acting opioid for those breakthrough pain moments) - When patients are on fentanyl patches, must make sure that patients are educated
Don’t put on broken skin
14
Q
If Mr TP is a 36 year old osteosarcoma patient with persistent bone pain. Patient says it is well controlled on current regimen. Taking:
- morphine controlled release 60mg PO TDS
- morphine syrup 10mg PO q4hrly PRN pain, avg 1-2 doses per day
Patient is having a hard time adhering to the TDS schedule and heard fentanyl patches might be more convenient.
Give a recommendation to switch to fentanyl patch. What is the dose and how to dosing instructions?
A
Student’s answer:
- 1 month’s supply, 10 patches
- Apply one 75mcg/hr fentanyl patch on unbroken skin every 72 hours
- They choose a dose in between of 50 and 90mcg
- Remember the duration of action for 1patch – 72hrs!!
How to decide between 2mg of morphine:1mcg or 3.6:1 ratio?
- Have 2 numbers so pick the middle (a valid way)
- This guy has been on morphine for a few months, so less scared of the side effects and more well controlled, ok so maybe want to be more aggressive. Or he never had fentanyl before so want to be more conservative
- Usually do 2mg:1mcg/hr since this is norm in the practice, the studies done for the table above is more conservative becos when it’s a drug company and want to sell drug, you cant have people dying on you:”)
- Need to consider patient factors e.g. how well can you trust the patient to take off the patch when the are in trouble, living alone? Blur? Brain cancer and cognitive impaired, so more conservative, i rather they be in pain than die of respiratory depression
- Some is based on experience, for the last 10 patients, you used 2:1 and they are ok:”)
For this case, he is taking the PRN 1-2 doses per day so it’s ok if we dont add it into the baseline. But if the patient is severely in pain 8-9 on the pain scale and is taking 7-8 doses per day then add some of that into fentanyl patch dose
Need to follow up and see how they do, be more aggressive up front, it is harder to scale back, so it’s sometimes better to be more conservative. Really depends on the situation:”)
15
Q
What is patient controlled analgesia?
A
PCA (patient controlled analgesia)
- The patient-controlled analgesia (PCA) pump is a computerized machine that gives you medicine for pain when you press a button. In most cases, PCA pumps supply opioid pain-controlling medicines such as morphine, fentanyl and hydromorphone
- Self-limiting
If patient give themselves too much, they will fall asleep and so won’t continue pressing the button to give themselves more so hard to be overdosed
16
Q
Usually what is the duration of opioid supply?
A
1 month
- For most opioids won’t give more than a month’s supply
Depending on laws/SOP, a month is a reasonable amount
17
Q
What is the usual purpose of giving methadone?
What is the MOA of methadone?
A
- Commonly think of methadone as an opioid that helps drug abusers like those on heroin/other opioids, need to give them an opioid so that they won’t have withdrawal symptoms, rather than a chronic pain reliever
- Methadone is a Mu agonist, but also have effects on NMDA, similar to sickle cell patients story/palliative care patients where they would put 800mcg/hr of fentanyl patches on their back, they develop tolerance, especially for those in end of life they get increasing need for pain meds and it becomes exponential
- Methadone is nice in the sense that it reverses this tolerance, the higher the baseline opioid use, you need to use less methadone comparatively
- NCCN put 3 ratios as shown above
18
Q
50 year old chronic cancer pain patient not controlled on morphine regimen.
Provider asks how to safely try methadone.
Patient currently is taking:
- Oxycodone Controlled Release Tablets 40mg BD
- Morphine 1mg/mL oral solution 5mL Q4H prn (averages 5 doses per day)
Dosing table:
Morphine — Methadone
- <60mg — 2-7.5mg / day
- 60-199mg — 10:1 (and patient < 65 y/o)
- 200 or more — 20:1 (and / or patient > 65 y/o)
Note: not to exceed initial dose of 45mg/ day of methadone
A
24 hour morphine equivalent = [40mg * 2 doses * (30mg morphine/20mg oxycodone)] + [5mg * 5 doses] = 145mg/day
smacked in the middle of the 60-199mg
- And patient is <65y/o
- So will use the 10:1 ratio
Starting methadone dose = 145mg * (1mg methadone/10mg morphine)
= 14.5mg
- Thus, Recommend methadone 5mg TDS AND increase prn morphine to 10-15mL Q4H prn.
- NB: Oxycodone controlled release 40mg PO BD about 3 times price of our calculated equivalent methadone 5mg PO TDS
- Don’t be too hard on the cut offs e.g. 199mg the ratio is 10:1 then if 200mg the ratio is 20:1
- Not only does methadone have effect on NMDA but it has a long half life similar to fentanyl patch, so need to counsel patients that what they feel now may not be similar to how they feel weeks from now.
- A lot of patients don’t like it even though it seems like a wonder drug on literature, becos it doesn’t give a nice CNS effect, like not nice euphoria
- Another down side of methadone is that only certain prescribers can prescribe methadone
19
Q
Which opioid can only be prescribed by certain prescribers?
A
Methadone
20
Q
The half life of methadone is similar to that of which opioid?
What is the half life — short or long?
A
Not only does methadone have effect on NMDA but it has a long half life similar to fentanyl patch, so need to counsel patients that what they feel now may not be similar to how they feel weeks from now.
21
Q
What is ketamine usually used for?
Thus is ketamine given alone or as an adjunct?
What are the side effects of ketamine?
A
- Anesthetic with some interesting properties in patients with opioid hyperalgesia (increase sensitivity to pain)
- End of life patients who get 800mcg/hr in fentanyl, so those who are not well controlled, might want to try ketamine.
- NUH we sometimes give orally in small doses
- Reverses opioid tolerance? Must reduce baseline opioid drastically when initiating (e.g. 50% or more) to avoid overdose
- Use their effect on NMDA to reverse the opioid tolerance, but don’t have a lot of pain relief effect so use in conjunction with opioids
- Difficult to use, many adverse events, questionable efficacy in literature
- Make it difficult to sleep, nightmares, hallucinations
- Don’t make small doses of ketamine so use anesthesia vials and compound syrup in NUH, so make own ketamine syrup and give small doses
- Getting more popular for other indications e.g. depression
- Ketamine is usually used in OR/OT as an anesthesia
It is one of the illicit drug trafficked in sg called special K
22
Q
What is the difference between opioid tolerance, dependence and addiction?
A
- Tolerance
- When patient ask for more opioids for pain, could be becos the current opioids they are taking are not effective anymore, not that the pain is getting worse or the condition is getting worse but becos of increasing tolerance
- Dependence
- Need the drug and without it, some harmful effects will happen. When on opioids for long period of time. Someone overdose and give naloxone to wake them up, but it will cause instant withdrawals.
- Addiction
- usually comes after opioid tolerance and dependence
- cutting down dose and controlling use is unsuccessful or can lead to social issues
23
Q
What kind of pain relievers are preferred for acute , subacute and chronic pain?
A
-
Non-opioid -therapies are at least as effective as opioids for many common types of acute pain
E.g. ketoprofen patches - Non-opioid therapies are preferred for subacute and chronic pain
24
Q
What are the pros of opioids over non-opioids (paracetamol / NSAID)?
A
- For opioids there is no ceiling, e.g. for panadol there is liver problem if overdose
For cancer say dont take paracetamol as if you do, it will mask a fever and won’t know when you are sick, so want a cleaner drug. - Opioids don’t have a lot of interactions depending on the opioid you use. NSAIDs have cardiovascular effects etc.
25
When first starting patients on opioids, what kind of release profile should the opioid have and what dose?
Immediate release and lowest dose
26
When starting / using opioids, what other medicines that patients are taking we should look out for?
**Benzodiazepines**, other **CNS depressants**, z hypnotics, barbiturates
E.g. have a **2 week limit on benzos** but the dr can overwrite especially with cancer patients
27
Which opioids are commonly abused in Sg?
1. Heroin
2. Ketamine
Ketamine is one of the top abused medications in Singapore
Heroin is still no.1 in terms of trafficked drugs
28
What are some adjuvants (medications aside from opioids) used for chronic pain?
Adjuvants
1. Gaba acting anticonvulsants
- **Gabapentin**
- **Pregabalin** → now this is generic so use this over gabapentin, but still use a lot of gabapentin
2. SNRIs e.g. **duloxetine**
3. **Tramadol** – 2 for 1?
- Mu agonist (~90%) and a serotonin reuptake inhibitor effects (10%)
- Get some neuropathic benefits
4. **Lidocaine** patches
- NUH dont give this out often but good for neuropathic pain, e.g. use 5% lidocaine patch not just for the local pain but general pain relief
29
What is palliative care?
* Encompassing and broad / **holistic** approach
* At any stage and trying to push it earlier and earlier
* Different from best Supportive/Comfort Care
* Pain and symptom control
* Improvement of quality of life
* A multidisciplinary team
* Also known as hospice care
* could include treatment that delay symptoms
30
What is Best Supportive/Comfort Care?
This is usually when we **withdraw from our therapeutic treatments** e.g. have infection dont get antibiotics, or cancer don’t get chemotherapy anymore as the harms outweigh the benefits so just make the patient feel better
31
What is hospice care?
- include the palliative care + best supportive care
- **actively dying** and usually in the **next 6 months**
32
What are the end of life syndromes?
1. Dyspnea
2. Secretions
3. Agitation / delirium
4. Bowel obstruction
5. Anorexia / cachexia
6. Persistent nausea
7. Chronic diarrhea / constipation
8. Insomnia / over-sedation
9. Wound care / pressure ulcers
33
What are some ways to treat someone with dyspnea (end of life syndrome)?
End of Life Syndromes: Dyspnea
- Common in lung cancer patients
- **Non-pharmacologic** approaches should be considered
- **Oxygen therapy** may be helpful in some cases, remember to **consider if had previous bleomycin chemotherapy** → becos concomitant use can cause pulmonary toxicity / lung damage
- **Morphine prn** is routinely seen prescribed at NUH, titrated to respiratory rate (**to breathe slower / ease the shortness of breath**)
- Sometimes end of life patients get morphine is not even for pain but for dyspnea
34
What are some ways to treat someone with secretions (end of life syndrome)?
End of Life Syndromes: Secretions
- **Saliva or other fluids build up in patient’s throat**
- **Glycopyrrolate** sometimes prescribed (but exempt in Singapore) (anticholinergic)
Kept in NUH
- **Anticholinergics** used (since widely available) but **carefully weigh toxicities and patient preferences** → to reduce secretions / cause dryness
E.g. **scopolamine, hyoscamine, atropine**
35
What are some ways to treat someone with agitation/delirium (end of life syndrome)?
End of Life Syndromes: Agitation/Delirium
- We’re there to push back against treating
- Pharmacists should always **look for medication related causes or contributors** to delirium and look for **alternatives** or consider **deprescribing**
- **Antipsychotics** seen as an option of **last resort** due to questionable efficacy and undesirable AEs, although anecdotally atypical antipsychotics are increasingly being used to perhaps safer effect (e.g. patient is punching the nurses)
36
What are some ways to treat someone with bowel obstruction (end of life syndrome)?
End of Life Syndromes: Bowel Obstructions
Patient case:
SNW 67 year old with metastatic gall bladder cancer with **recurrent bowel obstructions**. Gastric tube for venting place but the **tube would be frequently clogged** resulting in persistent N/V and severe abdominal discomfort.
What to recommend?
- He recommended **pancreatic enzymes and bicarbonate** and put it in the tube. It unclogged the tube. He learnt it from dieticians in the wards instead of from school or literature (non-evidence based medicine)
37
How to treat the other end of life syndromes?
End of Life Syndromes: Other Common Ailments
1. Anorexia/cachexia (wasting syndrome / body breaks down calories faster than usual)
- **Food supplements**, mega straw (but can cause blood clots) need to take a lot fo tablets becos we don’t have to concentrate to liquid form
- Cannabis in US for appetite stimulant, but in sg usually give them **tasty food supplements** e.g. milk feeds
2. Persistent nausea
3. Chronic diarrhea/constipation
4. Insomnia/over-sedation
- Tough
- Give drugs that are not really taught in sch/not good evidence on it e.g. **amphetamines** (CNS stimulant drug), **modafinil** (help stay awake)
5. Wound care/pressure ulcers
- Nurses do this but we will supply **barrier cream**, but this is not a replacement of **non-pharm/good turning**
38
What is advanced care planning?
What is advanced care planning?
- You want to DNR or DNI, **do not resuscitate** or **do not incubate**
- What treatments you want
39
What is the conclusion of the study on early palliative care for patients with metastatic non-small-cell lung cancer?
for exams!!
In this study, they randomized patients with advanced lung cancer to either see a **palliative care physicians or advanced practice nurses** or **usual care**, and get referred to palliative care when the oncologist says things that they needed
Early palliative care:
- **Improve QOL, mood, depression scores**
- **Lower proportion had aggressive end-of-life care e.g. so less ICU admissions, intubations**
This paper actually showed us survival benefits, each time the line dropped it means a patient dies.
So on avg, a patient has a **higher risk of dying not getting the palliative care** and these patients have a better QOL since in palliative care, and they have less aggressive end of life care so less ICU admissions, intubations etc.
So the **palliative care patients lived longer** not because we did all these life sustaining therapies, but it’s the opposite
The separation in the curve is rather huge, where cancer therapeutics usually don’t have such distinct separation in the curves
40
Which of the following is NOT a CDC recommendation on best practices when prescribing opioids for pain management?
A) Non-opioid therapies are considered first line for subacute and chronic pain, therefore a patient must first fail optimal doses of non-opioid therapies before initiating opioids
B) When initiating opioids, immediate release formulations should be used first and carefully assessed before adding extended release/long acting opioids. Transdermal fentanyl and methadone are highlighted as being more challenging to prescribe safely.
C) Successful tapering of chronic opioid use may require a careful and thoughtful collaboration with patients and in some instances can take months to years to accomplish.
D) Opioid use disorder is defined by DSM-5 criteria and has evidence based treatments which should be given to patients with this disorder
Ans: A
* Pain ladder: not necessary to start from the lowest ladder; don’t have to try non-opioid before going to opioid, can straightaway go to opioid
* B: fentanyl not usually used for opioid naive, should use morphine or oxycodone, then once the dose is stable, cross to fentanyl so reduce need for oral painkillers. But even when using the patch, need breakthrough painkiller like morphine syrup or oxycodone tablet / syrup.
* C and D are CDC recommendations
* Need to understand the concept of the pain ladder
* Opioids use disorder – opioid addiction, persistent use of opioids despite harmful consequences caused by their use
* DSM-5 criteria: impaired control, physical dependence, social problems, risky use
41
Which of the following statements regarding cancer pain therapies is FALSE?
A) Methadone has a long and variable half life and its full effect may not be seen for up to 72 hours.
B) Morphine and pethidine are generally not recommended in patients with renal dysfunction due to accumulation of metabolites.
C) Transdermal fentanyl is recommended only in patients who are opioid tolerant.
D) Pharmacogenetic variants and drug-drug interactions may have significant impact on commonly prescribed cancer pain therapies.
Ans: A
* Wrong because the effect is not 72h - search NCCN guidelines. 72h: 3d. But need to titrate every 5-7 days (full onset is reached at day 5-7). So it is 5-7 days for steady state.
* B: true. Renal dysfunction, don’t use morphine or pethidine
* C: transdermal patch for opioid tolerant, not opioid naive
* D: can impact.
42
Which of the following therapies would be the LEAST effective when treating opioid induced constipation?
A) Psyllium (aka ispaghula) husks
B) Sennosides
C) Lactulose
D) PEG
Ans: A
* Psyllium: bulk-forming, like fibre. Not used as opioid induced constipation reliever as drawing water?? to stool wont work due to opioid MOA - mu receptor antagonist (i.e. paralyses the gut). The gut wont move as well.
* Will worsen: more fibre, stool gets bigger and larger, harder to come out
