Introduction to Non-Opioid and Opioid Pain Therapy Developed by: Jillian Baer, PharmD, BCPS Updated by: Jennifer L. Johansen, PharmD, BCPS Sr. Manager,

Introduction to Non-Opioid and Opioid Pain Therapy

Developed by:Jillian Baer, PharmD, BCPSUpdated by:Jennifer L. Johansen, PharmD, BCPSSr. Manager, Drug [email protected]

Presented by:

Steve Gilbert, BSc, MBA, CGP, BCPSDirector, Clinical Support

[email protected]

Disclaimer Statements

• This presentation is for educational purposes only. It is not intended as

legal or professional advice. Any reproduction by Third Parties of this

presentation or materials contained herein is prohibited in the absence

of written permission obtained from the author.

• Review or discussion of any agent does not alter in any way the

conditions for use contractually agreed upon and outlined in the

Hospice Pharmacia Medication Use Guidelines.

excelleRx, Inc. All Rights Reserved. 2012


•Release date: 11/28/2012; Expiration date: 11/28/2013

•This program was developed for the beginner to advanced nurse working in the hospice and/or palliative care environments.

•Requirements for statement of credit:

–Listen to entire presentation; Complete and submit post-test via Xeris with a passing score of at least 70%.

•Statements of credit: Awarded and sent via email, within 4 weeks after receipt of post-test

•This program may contain content that discusses the off-label use of various medications

•The program developer/presenter declare no conflicts of interest or relevant financial relationships

•No financial support was obtained or provided for any component of the educational activity from any commercial interest or any other organization.

•There are no registration fees. There is a small, processing fee of $11 to be accessed per statement of credit issued to hospice partner participants and will appear on the hospice organization’s monthly bill.

Provider approved by the California Board of Registered Nursing, Provider Number CEP 15693 for 1.0 contact hours

Learning Objectives

• Describe how pain is classified

• Discuss and perform a proper pain assessment

• Recognize the differences between the various common non-opioid and opioid therapies used in pain management

• Recommend appropriate non-opioid and opioid pain therapies


Why this topic?• > 50 million Americans suffer from chronic pain, and ~25 million

Americans experience acute pain each year due to injuries or surgery

• ~70% of patients w/cancer experience significant pain during their illness, yet < 1/2 receive adequate pain treatment.

• ~50% of all hospitalized patients have moderate to severe pain in their last days of life.

• > 20% of Americans aged 60 and over have chronic pain due to arthritis, other joint pain or back pain.

• National Pain Survey, Conducted for Ortho-McNeil Pharmaceutical,1999• Stuart Grossman et al, “Correlation of patient and caregiver ratings of cancer pain.” Journal of Pain and Symptom Management 1991 (6:2) 53ff.; Jamie H. Von

Roenn, et al, “Physician Attitudes and Practice in Cancer Pain Management.” Annals of Internal Medicine 15 July 1993 (119:2) 121ff • SUPPORT investigators, “A controlled trial to improve the care for seriously ill hospitalized patients.” Journal of the American Medical Association 1995 (274):

1591ff


Pain never killed any one.

True or False?

Post-op pain can delay healing and contribute to complications that

may be life-threatening


Pain

• An unpleasant sensory and emotional experience associated with actual or potential tissue damage. (APS, 1992)

• Whatever the patient says it is! (McCaffery, 1968)

• Impacts psychosocial and physical functioning


Classification of Pain: Chronic vs. AcuteCharacteristic Acute Pain Chronic Pain

Temporal Recent onset, expected to last no longer than days or weeks; generally follows tissue injury and resolves with healing

Remote, often ill-defined onset

Intensity Variable Variable

Associated Effect Anxiety if pain is severe or cause unknown; sometimes irritability

Irritability or depression

Associated behaviors Pain behaviors (e.g. moaning, rubbing, splinting) may be prominent when pain is severe

May or may not give any indication of pain; specific behaviors (e.g., assuming a comfortable position may occur)

Associated Features Sympathetic hyperactivity if severe pain (e.g., tachycardia, hypertension, sweating, mydriasis)

May or may not have vegetative signs such as: lassitude, anorexia, weight loss, insomnia, loss of libido


Classification of Pain: Incident vs. Breakthrough

• Incident– Precipitated by movement or procedures

• Breakthrough– Between regularly scheduled doses of pain medication


Classification of Pain:Nociceptive vs. Neuropathic

PainPain

NociceptiveNociceptive NeuropathicNeuropathic

SomaticSomatic VisceralVisceral CentralCentral PeripheralPeripheral

MixedMixed


Nociceptive Pain: Somatic Pain

• Arises from bone, joint, muscle, skin, or connective tissue

• Described as: aching, throbbing, sharp, worsens with movement

• Well localized

• Examples: muscle spasm, bone metastases, incisions, tumor invasion into surrounding tissue, broken bone.

Pain

Nociceptive Neuropathic

Somatic Visceral


Nociceptive Pain: Visceral Pain• Stretching or distention of pelvic,

thoracic, or abdominal viscera

• Described as: deep, squeezing, pressure

• Often poorly localized, may be referred along a dermatome

• Examples: Myocardial infarction, hepatic metastases, bowel obstruction

Pain


Somatic Visceral


Neuropathic Pain

• Pain reports may be disproportionate to physical findings

• Serves no protective function

• Described as: sharp, shooting, tingling, stabbing, electric, numbness, burning

• Examples: spinal cord compression, shingles, peripheral neuropathy

Pain



Quality of LifeQuality of LifeQuality of LifeQuality of Life

ImmuneImmuneImmuneImmune

CognitiveCognitiveCognitiveCognitive

MusculoskeletalMusculoskeletalMusculoskeletalMusculoskeletal GastrointestinalGastrointestinalGastrointestinalGastrointestinal

GenitourinaryGenitourinaryGenitourinaryGenitourinary

RespiratoryRespiratoryRespiratoryRespiratory

CardiovascularCardiovascularCardiovascularCardiovascular

MetabolicMetabolicMetabolicMetabolic

UnrelievedUnrelievedPain Pain

UnrelievedUnrelievedPain Pain

(McCaffery, 1999)


Unassessed pain = Untreated Pain• Physical

– Fatigue, decreased activity– Nausea– Insomnia– Poor appetite

• Psychological– Depression– Anxiety– Anger, irritability, agitation– Loss of control– Decreased cognition


Assessment Overview

• The APS (American Pain Society) calls pain the “5th Vital Sign”– Assess when HR, BP, RR & Temp. are measured

• Goal of initial assessment– Characterize pain by location, intensity, etiology

• Detailed history• Physical Exam• Psychosocial assessment• Diagnostic evaluation


When Should Assessment Occur?

• Upon admission– To identify a pain problem– Establish a baseline/history– Serve as a guide for care/treatment

• At regular, ongoing intervals after starting treatment

• With each new report of pain

• At appropriate intervals after intervention (i.e. 12-18 hours after fentanyl patch initiation)

– KEY: know the onset of action and peak effect of the medication


Elements of a Comprehensive Pain Assessment

Physical ExamComplete History

Laboratory andRadiologic Tests


“PQRSTU” Pain Assessment Mnemonic

P: Palliating/Precipitating factors– What makes your pain better? Worse? Movement? Hygiene care?

Q: Quality – Describe your pain for me?

R: Radiation or pattern– Does the pain move from one place to another or does it stay in one place?

Where?S: Severity or site

– On a scale of 0-10 with 0=no pain and 10=worse pain possible, where is your pain now? At its worst? At its best? After you take pain medication?

T: Temporal nature – Is your pain constant or intermittent? How long have you had this pain?

U. YOU! – What are your pain management goals including intensity, QOL and activity

level? What does your pain mean to you?


Pain Assessment ScalesSimple Descriptive Pain Distress Scale [1]

None Annoying Uncomfortable Dreadful Horrible Agonizing

|___________|___________|____________|__________|___________|

0-10 Numeric Pain Distress Scale [1]

No Distressing Unbearable pain pain pain

|_____|_____|_____|_____|_____|_____|_____|_____|_____|_____|

0 1 2 3 4 5 6 7 8 9 10

Visual Analog Scale (VAS) [2] No Unbearable distress distress |___________________________________________________________|

Wong-Baker FACES Pain Rating Scale


Patients at Risk for Poor Assessment

• Children

• Elderly

• Cognitively impaired persons/unconscious

• Non-English speaking

• Substance abuse history


Pain Assessment in Special Populations: Impaired Cognition

• Common finding in hospice patients

• Difficulty due to decreased memory, poor orientation, visual, and spatial skills


Pain Assessment in Special Populations: Impaired Cognition - Suggestions

• May need to repeat the scale more than once and give sufficient time for an answer

• Scale of 0-5 may be easier to use than 0-10 scale

• May require assessment by third party in nonverbal patients

• Need to use behavioral cues:– Facial expressions– Muscle tension– Gestures

• Look over a 5-minute period for frequency, intensity, and duration to rule out transitory, meaningless gestures


Pop Quiz!

• Andrew is 25 years old and this is his first day after abdominal surgery. As you enter the room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals the following information:BP: 120/80 HR: 80 RR: 18On a scale of 0-10 (0 = no pain, 10 = worst pain), he rates his pain as an 8.

• On the patient’s record you must mark his pain on the scale below. What is the number that represents your assessment of Andrew’s pain?

0 1 2 3 4 5 6 7 8 9 10No pain Worst

pain


Assessment Clinical Pearls

• Patient knows best – only the patient can describe and rate the pain!

• Choose the appropriate tool given the patient’s clinical status

• Once the appropriate tool has been selected, use it consistently with that patient to enable symptom tracking

• PQRSTU can be used for any patient complaint!


Medication Therapy


Drug Therapy: Overview of Pain Management Standards

• Right drug, right dose, right route, right schedule

• Start with minimal effective dose

• Reassess frequently

• Constant pain needs around-the-clock dosing AND breakthrough

• Plan/monitor for side effects & treat accordingly

• Use non-pharmacological therapies when appropriate

• Provide education

• Adjuvants for specific pain (ex. bone, neuropathic)


World Health Organization Approach

• By the mouth– Use oral route & least invasive route

whenever possible

• By the clock– Give ATC for constant pain with

appropriate breakthrough

• By the ladder– Assess pain severity & treat

accordingly

• For the individual– Selection of medication is patient-

based

• With attention to detail– Assess pain regularly, adjust ATC based

on breakthrough, watch side effects, etc.


Pain Treatment Options• Non-pharmacologic

– Heat/cold therapy– Massage– Physical/Occupational

therapy– Aromatherapy– Music therapy– Spiritual/Religious

counseling

• Pharmacologic– Non-opioids– Opioids– Adjuvants


Pop Quiz!

True or False?Non-opioids are not useful

analgesics for severe pain.

FALSE…depends on the type of pain!


Non-opioids• Acetaminophen (Tylenol®)

• NSAIDS (Non-steroidal anti-inflammatory drugs)

• Corticosteroids (Decadron®, Prednisone®)


Acetaminophen (Tylenol®)

• Mild musculoskeletal pains (osteoarthritis); Fever

• No anti-inflammatory effects

• Ceiling effect

• Fewer adverse effects– No risk for GI bleeding

• Liver toxicity (>4gm/day)– Elderly/patients with liver disease should use 3gm/day– Inc. risk with underlying liver disease or chronic alcoholism


NSAIDS• Mild-moderate inflammation related pain; Fever

– Bone metastasis, arthritis, soft-tissue infiltration, recent surgery

• Can enhance opioid-based analgesia– When inflammation is causing pain, addition of NSAID will often reduce

opioid requirements and provide better pain relief

• Combination of multiple NSAIDS not recommended– No evidence to suggest improved levels of analgesia

– Increased risk for adverse effects and drug interactions

• Ceiling effect


NSAIDS Adverse Effects

• GI toxicity– Reduced by adding a

proton pump inhibitor, H2 antagonist, misoprostol

• Kidney dysfunction– Inc. risk if patient

dehydrated; Altered kidney blood flow

• Confusion

• Fluid retention– May exacerbate heart

failure & hypertension

• Salicylism– Ringing in ears (tinnitus),

nausea, vomiting

• Platelet dysfunction– Reversed by stopping

NSAID– Stop Aspirin therapy 7 days

prior to invasive procedure


Corticosteroids: Place in Therapy

• Reduces cerebral and spinal cord edema/compression

• Reduces edema in other areas:– Rectal/cervical tumor affecting sacral area– Reduces capsular stretch in liver, spleen, lymph nodes and adrenal

glands causing visceral distention

• Stimulates appetite; creates feeling of well-being (euphoria)

• Effective for bone pain if inflammation is involved

• Overall effects: Mood elevation, anti-inflammatory, anti-emetic, euphoria, appetite stimulation, increased weight


Corticosteroids: Potency

Drug Equal DoseAnti-

inflammatory Potency

Sodium-Retaining Potency

Cortisone 25 mg 0.8 0.8

Dexamethasone 0.75 mg 25 0

Hydrocortisone 20 mg 1 1

Methylprednisolone 4mg 5 0.5

Prednisone 5mg 4 0.8

Dexamethasone produces the least amount of mineralocorticoid effect, with the highest amount of anti-inflammatory effect!


Corticosteroids: Adverse Effects

• Key Adverse Effects:– Insomnia/nervousness - Give last dose no later than 2-3pm in order

to minimize insomnia

– Hyperglycemic effects – Monitor patients with diabetes for changes in glucose control

– Edema, facial hair growth (with long term use)

– Weigh risks vs. benefits for use in patients with relative contraindications

• e.g. Diabetes; immunosuppression – What is more important at this point?


Case Discussion

Current medications: Lisinopril 20mg PO QD Metoprolol 50 mg PO BID Digoxin 0.125mg PO QD Furosemide 80mg PO QAM K-Dur 20 mEq PO QD Fluoxetine 20mg QD Loperamide 2-mg after each loose

stool • Allergies: Sulfa drugs

Assessment results: P: Constant; worsens with movement;

Aspercreme & heating pad Q: Achy R: Stays over joints; no radiation S: Almost all joints; Rates as 1-2/10; will

increase to 3-4/10 with movement T: Occurs at rest, at night, and w/

movement. U: Stiffness in knees/hips in the AM, but

decreases after dressing. Denies fatigue, weakness, and joint redness/swelling

GB is a 68-year-old male with a primary diagnosis of heart failure. His past medical history is significant for a seizure disorder, hypertension, and depression. He is complaining of generalized pain and his nurse would like to get a pharmacist

recommendation.


Opioids• Pain relief through binding to mu, kappa, & delta receptors

– In brain & spinal cord– Binding prevents release of certain neurotransmitters involved in

transmission of pain– Mu

• Analgesia, resp. depression, pupil constriction, euphoria, reduced GI motility

– Kappa• Analgesia, resp. depression, pupil constriction, dysphoria,

psychomimetic effects– Delta

• Analgesia


Types of Opioids


Opioid Agonists CodeineHydrocodoneOxycodoneMeperidinePropoxyphene

FentanylHydromorphoneOxymorphoneMorphine

Opioid Agonists/NMDA Receptor Antagonists

Levorphanol Methadone

Opioid Agonist/ Norepinephrine Reuptake Inhibitors

Tapentadol Tramadol

Mixed Opioid Agonist/Antagonists

ButorphanolMorphine/NaltrexonePentazocine

BuprenorphineNalbuphine

Antagonists Naloxone Naltrexone

Major Opioid Adverse Effects

Effect Manifestation

Mood changes Dysphoria, euphoria

Somnolence Lethargy, drowsiness, apathy, inability to concentrate

Stimulation of CTZ; Delayed gastric emptying

Nausea, vomiting

Respiratory depression Decreased respiratory rate

Decreased GI motility Constipation

Increased sphincter tone Biliary spasm, urinary retention

Histamine release Hives, itching, asthma exacerbation (rare)

Tolerance Larger doses for same effect

Dependence Withdrawal symptoms w/ abrupt d/c Adapted from Dipiro et al.


Morphine Short-acting (MSIR®, RoxanolTM)

Long-acting (MsContin,® Kadian®)• “Gold Standard” of opioid agonists - most experience and data

• Can be administered via many routes, i.e. oral, rectal, sublingual, IV/ IM/SC, epidural/intrathecal

• Pharmacokinetics:– Significantly metabolized in the liver:

• Morphine 3-glucuronide (toxic)• Morphine 6-glucuronide (active, potentially toxic)

– Bioavailability ~ 40%• Hepatic disease/impairment can actually increase

bioavailability– Eliminated via glomerular filtration (risk in patients with renal

dysfunction)


Hydromorphone Short-acting (Dilaudid®)

• Alternative to morphine – not superior in efficacy

• Can be administered via many routes, i.e. oral, rectal, sublingual, IV/ IM/SC, epidural/intrathecal

• Pharmacokinetics– Significantly metabolized in the liver:

• Hydromorphone 3-glucuronide (toxic)• Hydromorphone 6-hydroxy metabolites (active in animals, not

in humans)– Bioavailability ~ 60%

• Hepatic disease/impairment can actually increase bioavailability

– Eliminated via urine primarily as hydromorphone 3-glucuronide (potential for renal accumulation of toxic metabolite)


Oxycodone Short-acting (OXYIR®, Oxyfast®)

• Alternative to morphine – not superior in efficacy

• Routes of administration: oral, rectal (except long-acting)

• Available in combination with acetaminophen (Percocet®) or aspirin (Percodan®)

• Pharmacokinetics– Oxidized in the liver:

• Approximately 95% noroxycodone (inactive, questionable toxicity)

• Approximately 5% oxymorphone (active, twice as potent, accumulates in renal impairment)


FentanylLong-acting (Duragesic®)

• Alternative to morphine – not superior in efficacy, one study reports less constipating

• Various routes of administration – transdermal, IV/IM/SC, transmucosal, intranasal, epidural/intrathecal

• Pharmacokinetics– Poor oral bioavailability– Metabolized in the liver to inactive metabolites– Does not accumulate in renal dysfunction – may be preferred in

patients with renal dysfunction


Transdermal Fentanyl (Duragesic)• Rate of drug delivery is not the same on all 3 days

– Day 1 – concentration gradient jump-started– Day 2 – concentration gradient established and starts to slow down– Day 3 – concentration gradient reaches equilibrium

• Significant amount of fentanyl left in patch after dosing interval is complete

• Never occlude, cut, or “half” patches to titrate dose


Transdermal Fentanyl: Patient Considerations• Patient’s pain is unstable

– 12-17 hour delay in onset of pain relief for transdermal fentanyl makes titration difficult in the face of a changing pain picture

• Secondary diagnoses: DM, PVD, CHD, HTN, etc.– Patient’s circulation may not be sufficient to carry fentanyl from the

subcutaneous depot to central sites

• Lean body mass– May not be enough subcutaneous fat to allow for a depot

• Subject to changes in body temperature– Changes in skin temperature will change absorption rate of fentanyl

• Medication Requirement– Not for opioid naïve patients. Should only be used in patients who have

demonstrated tolerance and who require total daily dose of at least equivalent to transdermal fentanyl 25mcg/hr (i.e. oral morphine of 60mg.day)

– Doses > 500-600mcg/hr are difficult to administer due to limitation of areas to rotate patch application


Methadone (Dolophine®, Methadose®)• Synthetic Opioid

• Quick onset of action (~30-60 mins) and high bioavailability (~ 80% PO)

• Long-acting properties naturally– The only liquid “long acting” opioid– Acute dosing has relatively short half-life– Elimination half-life increased with chronic dosing

• Up to 130 hours– Long acting properties start to take effect with chronic use

• No toxic metabolites– No dosage adjustment needed for renal impairment

• Typical starting dose: 2.5mg-5mg PO q12h or q8h


Methadone: Mechanism of Action

• R-isomer has opioid properties– Different receptor activity

from traditional opioids– Greater affinity for delta

receptors– Very potent analgesic– Less affinity for mu

receptors– Less constipation,

hallucinations, euphoria

• S-isomer has neuropathic adjuvant properties– NMDA receptor antagonist– Can undo “wind up”

phenomenon– Norepinephrine reuptake

inhibitor– Serotonin reuptake

inhibitor

Methadone is a racemic mixture (R+S)


Potential Situations for Methadone Use for Pain

Morphine Allergy Renal Impairment Neuropathic Pain

Opioid Adverse Effects Not swallowing solid dosage forms

Refractory Pain


Methadone…Challenging Situations

Limited Prognosis Multiple Drug Interactions

Lives alone, unreliable, poor cognitive functioning

Syncope, Arrhythmia,QT Prolonging Drugs


Methadone prescribing requires knowledge of its:

Unique pharmacodynamic and pharmacokinetic properties

Potential for drug interactions and side effects

Complex conversion ratios and protocols


Consult with knowledgeable prescriber and/or pharmacist

BEFORE starting therapy with methadone


Methadone For…Pain Control vs. Addiction Maintenance

• Federal law prohibits pharmacies from dispensing methadone for addiction maintenance

• There are no limitations for dispensing methadone for pain control

• Common doses for addiction are high and given once daily


Long-Acting Opioid Cost Considerations Equianalgesic drug regimen Qty {15 day supply} Approximate cost

Exalgo® (Hydromorphone)32mg daily

15 tablets $$$$$$

Morphine LA tablet60mg q12h

30 tablets $$$

Kadian ® (LA Morphine capsule)120mg daily

15 capsules $$$$$

OxyContin® (Oxycodone)40mg q12h

30 tablets $$$$$$

Transdermal Fentanyl50mcg q72h

5 patches $$$$$

Methadone5mg q8h

45 tablets $


Case Discussion

Current medications include:• Insulin glargine 40 units once daily • Insulin aspart SSI prior to meals• Casodex (Bicalutamide) 150mg PO

once daily• Amlodipine 5 mg PO once daily• Allergies: No known allergies

Assessment:• P: Woke up with pain one AM & has remained

since. Has not tried any medication for the pain.

• Q: Nagging throb• R: Pain does not really go anywhere.• S: Located primarily in hips and legs. 2/10 at

worst.• T: Pain started ~3 days ago and has continued

intermittently. Worsens when transferring from wheel chair to bed.

• U: Has made transferring and requires help of his wife - difficult for her due to decreased strength. She fears that she will be unable to get him in and out of his wheel chair and that he will then become isolated

JW is a 65-year-old male with a primary diagnosis of prostate cancer. He is experiencing generalized pain. He has a history of chronic renal insufficiency, hypertension, and diabetes. He is restricted to a wheel chair secondary to an injury he sustained while enlisted in the military. As a result of his disease process, he has also begun to complain of a loss of appetite leading to weight loss.


Opioid Combination Products

• Takes advantage of central and peripheral mechanisms of action potentiated analgesic effect

• Primary limitation: maximum daily dosage of non-opioid component (APAP, ibuprofen)– Examples:

• Hydrocodone/acetaminophen• Hydrocodone/ibuprofen• Oxycodone/acetaminophen• Oxycodone/aspirin• Codeine/acetaminophen• Tramadol/acetaminophen


Opioid Selection: Poor Choices for Chronic Pain

• Meperidine– Poor absorption and toxic metabolites

• Propoxyphene– Poor efficacy, low potency and toxic metabolites

• Mixed agonist-antagonist– Compete with agonists -> possible withdrawal– Analgesic ceiling effect


Approach to Opioid DosingApproach to Opioid Dosing

Opioid Naïve:Start low, go slow!

Opioid Tolerant

Intermittent Pain:PRN Doses

Persistent/Chronic Pain1. PRN doses x 48 hrs2. Determine ATC needs and

give breakthrough q3-4 h: 10-20% of TOTAL long acting requirement

Stable and Tolerating: Stay on current regimen

Stable and Not Tolerating: Consider opioid rotation

Unstable and Tolerating: Keep current opioid, but by 25-100% depending on pain severity

Unstable and Not Tolerating: Consider opioid rotation



Titrate only when there is inadequate pain relief without side effects


When Do We Consider Opioid Rotation?• Unmanageable or intolerable adverse

effects

• Lack of acceptable analgesia/therapeutic effect

• Change in patient status – Patient difficulty in adhering to regimen– Difficulty swallowing– Transition from inpatient to home care


Goals for Opioid Rotation• Select an opioid analgesic and develop a dosing regimen that will:

– Effectively and safely manage the patient’s pain

– Minimize the risk for adverse effects


What to do after converting?• It may take 3-5 days or longer for a complete transition to occur

• During this time, it is essential to reassess the patient’s pain and monitor for adverse effects.

• Titrate the new opioid as needed– Short-acting, oral immediate release, single ingredient opioids:

• May be increased every 2 hours

– Long-acting, oral sustained-release opioids:• May be increased every 24 hours • Does not include methadone or transdermal fentanyl


Pain in Last Days of Life

• Clinical presentation– Facial grimacing– Body stiffening– Diminished kidney function

• Decreased perfusion, decreased clearance and accumulation of toxins


Pain in Last Days of Life• What do we do?

– Assess patient to best ability and patient tolerability

– Rule out other causes of distress if possible & treat other symptoms if present

• Agitation, constipation, urinary retention

– Try opioid to see if behaviors diminish

– Palliative sedation may be the only viable option• Intolerable pain and/or suffering• Refractory to various aggressive interventions• Intention is mitigation of distress, not to hasten death


Thank you for your participation!Any Questions?


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pp 1103-1116.• 3. FitzGerald GA. Coxibs and Cardiovascular Disease. NEJM 2004; 351(17): 1709-1711.• 4. FitzGerald GA. COX-2 and beyond: approaches to prostaglandin inhibition in human disease. Nat Rev Drug

Discov 2003;2:879-890.• 5. FitzGerald GA, Patrono C. The coxibs, selective inhibitors of cyclooxygenase-2. NEJM 2001;345(6):433-442.• 6. Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR

Publication No. 94-0592. Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, March 1994.

• 7. Levy MH. Pharmacologic treatment of cancer pain. NEJM 1996;335(15);1124-1132.• 8. NSAID Alternatives. Med Lett Drugs Ther 2005;47:8.• 9. Payne R. Opioid Pharmacotherapy. In. Berger A, Portenoy RK, Weissman DE. Eds. Principles and Practice of

Palliative Care and Supportive Oncology. Philadelphia 2002. pp 68-83. • 10. Solomon DH, et al. Relationship between selective cyclooxygenase-2 inhibitors and acute myocardial infarction

in older adults. Circulation2004;109:2068-2073.• 11. Wallenstein D, Portenoy R. Nonopioid and Adjuvant Analgesics. In. Berger A, Portenoy RK, Weissman DE. Eds.

Principles and Practice of Palliative Care and Supportive Oncology. Philadelphia 2002. pp 84-97. • 12. Walsh D. Pharmacological management of cancer pain. Semin Oncol 2000;27:45-63.• 13. Wong DL et al. Wong’s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby,

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Introduction to Non-Opioid and Opioid Pain Therapy Developed by: Jillian Baer, PharmD, BCPS Updated by: Jennifer L. Johansen, PharmD, BCPS Sr. Manager,

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