1 What Do You Mean The Morphine Isn’t Working? Ellen Fulp, PharmD, BCGP Clinical Education Coordinator AvaCare, Inc. Innovation and Excellence in Advanced Illness at End of Life 42 nd Annual Hospice & Palliative Care Conference – September 2018 – Charlotte, NC Objectives • Discuss the current U.S. opioid epidemic • Review recommendations for safe prescribing and use of opioid analgesics • Examine appropriate use of non-opioid analgesics in hospice and palliative care • Explore patient cases highlighting methadone, high dose opioid infusions, and opioid sparing medications Innovation and Excellence in Advanced Illness at End of Life The Carolinas Center’s 42 nd Annual Hospice & Palliative Care Conference – September 2018 – Charlotte, ,NC Opioid Epidemic Innovation and Excellence in Advanced Illness at End of Life
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What Do You Mean The Morphine Isn’t Working?
Ellen Fulp, PharmD, BCGP
Clinical Education Coordinator
AvaCare, Inc.
Innovation and Excellence in Advanced Illness at End of Life 42nd Annual Hospice & Palliative Care Conference – September 2018 – Charlotte, NC
Objectives
• Discuss the current U.S. opioid epidemic
• Review recommendations for safe prescribing and use of opioid analgesics
• Examine appropriate use of non-opioid analgesics in hospice and palliative care
• Explore patient cases highlighting methadone, high dose opioid infusions, and opioid sparing medications
Innovation and Excellence in Advanced Illness at End of Life The Carolinas Center’s 42nd Annual Hospice & Palliative Care Conference – September 2018 – Charlotte, ,NC
Opioid Epidemic
Innovation and Excellence in Advanced Illness at End of Life
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Opioid Epidemic
2,100,000People with an opioid use disorder
42,249 People died from opioid overdoses
948,000People used heroin
$504,000,000Economic cost
Innovation and Excellence in Advanced Illness at End of Life
Pain Assessment
• NQF #1634 Pain Screening
• Measure Description: Percentage of patient stays during which the patient was screened for pain during the initial nursing assessment.
• NQF #1637 Pain Assessment
• Measure Description: Percentage of patient stays during which the patient screened positive for pain and received a comprehensive assessment of pain within 1 day of the screening.
• location, severity, character, duration, frequency, what relieves or worsens that pain, and the effect on function or quality of life
Innovation and Excellence in Advanced Illness at End of Life
Pain Assessment
• Pain Intensity Assessment Tools
• Visual Analogue Scale
• Numeric Rating Scale
• Verbal Descriptor Scale
• FACES Scale (Wong-Baker)
• Faces Pain Scale- Revised
• Pain Thermometer
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Opioid Risk Tool (ORT)
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REMS
• Education– Expectations: goals and quality of life – Opioid Therapy: safe storage, reliable caregiver, tablet
• Newer concerns: neuropsychiatric, urinary and hepatobiliary toxicity
• Common adverse effects at subanesthetic doses: feeling “spaced out”, nausea, sedation, delirium• Pre-medicate: haloperidol or lorazepam
• Caution: known brain mets
Innovation and Excellence in Advanced Illness at End of Life
Ketamine
• Patient Counseling
• Report any unusual thoughts or changes in movement
• Take this medication exactly as prescribed
• Store in a safe place and do not share with others
• You may require less of your maintenance pain medications over time• Report feelings of sedation
• Do not stop or start new medications without speaking to your care team
• You should not take ketamine if you have a history of seizures, head trauma, increased blood pressure, or are sensitive to ketamine
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Patient Case: Lynn
• Psychiatric history screening- negative
• Ketamine test dose
• Ketamine 25mg PO TID
• Opioid dose reduction: 50%
• Stop ketamine
• Burst therapy
Innovation and Excellence in Advanced Illness at End of Life
Questions
Innovation and Excellence in Advanced Illness at End of Life
References
• Anderson, S. L., & Shreve, S. T. (2004). Continuous subcutaneous infusion of opiates at end-of-life. Annals of Pharmacotherapy, 38(6), 1015-1023.
• Berna, C., Kulich, R. J., & Rathmell, J. P. (2015, June). Tapering long-term opioid therapy in chronic noncancer pain: Evidence and recommendations for everyday practice. In Mayo Clinic Proceedings (Vol. 90, No. 6, pp. 828-842).
• AAHPM Methadone Dose Conversion Guidelines.• Chou, R., Cruciani, R. A., Fiellin, D. A., Compton, P., Farrar, J. T., Haigney, M. C., ... &
Mehta, D. (2014). Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. The Journal of Pain, 15(4), 321-337.
• McLean, S., & Twomey, F. (2015). Methods of rotation from another strong opioid to methadone for the management of cancer pain: a systematic review of the available evidence. Journal of pain and symptom management, 50(2), 248-259.
• Covington-East, C. (2017). Hospice-Appropriate Universal Precautions for Opioid Safety. Journal of Hospice & Palliative Nursing, 19(3), 256-260.
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References
• Prommer, E. (2012). Ketamine for pain: an update of uses in palliative care. Journal of palliative medicine, 15(4), 474-483.
• Prommer, E. (2016) Fast Fact # 132: Ketamine use in palliative care. Palliative Care Network of Wisconsin.
• Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
• Webster, L. Opioid Risk Tool. http://www.lynnwebstermd.com/opioid-risk-tool/ . 2018. Accessed August 7, 2018.
• NIH. Overdose Death Rates. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates . September 2017. Accessed August 7, 2018.
Innovation and Excellence in Advanced Illness at End of Life