The primary focus of hospice care is the palliation of symptoms. These guidelines review the basics of pain and symptom management. The initial plan, ongoing revisions in the plan, and evaluations of its effectiveness must be the joint effort of the hospice nurse, attending physician, hospice medical director, patient/family, other members of the hospice team, and pharmacist. The dosages listed in these guidelines are the usual adult dosages, but smaller doses are recommended for older patients, or those with renal or hepatic impairment. All unusual or unexpected reactions to a medication must be reported promptly to the attending physician and/or the medical director. Questions or concerns may be directed to one of the following at 847-685-9900: Patient Care Manager, Director of Clinical Operations, Medical Director.

Essential to effective pain control is acceptance of the broadest definition of pain -- pain is whatever the patient states it is. The alleviation of that pain becomes the goal of the hospice care team.

These guidelines are based in part on the Management of Cancer Pain: Clinical Practice Guidelines, published by the Agency for Health Care Policy and Research (1994).

A. General Principles of Pain Control:

Assessment of pain is important for successful treatment. Initial assessment consists of history, physical exam, and psychosocial evaluation. The patient should describe the pain pattern, intensity, characteristics, duration, and aggravating and alleviating factors. Continued assessment is needed after any change in the patient’s condition or treatment plan.

An objective rating scale (0 to 10 is recommended) should be taught to the patient and used as an ongoing means of evaluating the effectiveness of the pain control regimen.

Whenever possible, the cause of pain should be determined in order to direct the most effective means of pain control.

Pain experienced by the terminally ill patient is most often chronic in nature. Effective pain control, therefore, requires regularly administered doses of medication (not prn dosing).

Non-pharmacological interventions should be utilized as an adjunct to pain control. These measures can include the following: relaxation techniques, distraction, cutaneous massage, guided imagery, and biofeedback.

B. Use of Pain Medications:

Use of the World Health Organization’s analgesic ladder is the recommended approach to selecting treatment options.

The five basic concepts of the WHO ladder for controlling pain:

1. by the mouth
2. by the clock
3. by the ladder
4. for the individual
5. with attention to detail

For mild pain (such as osteoarthritis or other mild pain), start with nonopioids, such as acetaminophen (650 mg Q4H or 1000 mg Q6h), ibuprofen (200-800 mg TID), or other nonsteroidal.

For moderate pain (pain not expected to be relieved with OTC remedies) use a weak opioid, such as acetaminophen/ hydrocodone (Vicodin), up to 8 tablets in 24 hours. Also consider acetaminophen/ oxycodone (Roxicodone), up to 8 in 24 hours. The use of all of these combination agents is limited by the ceiling dose of acetaminophen (4,000 mg/day - less in those with impaired liver function) or the ceiling dose of ibuprofen (2400 mg/day - less in those with severe renal impairment)

For persistent or more severe pain, morphine is the drug of choice. Morphine is available in a wide variety of dosage forms. It is best begun in an immediate-release form, such as MSIR or Roxanol, orally, every 4 hours. Once a satisfactory level of pain control is reached with immediate-release morphine, the total daily dose should be calculated. Change to a longer acting form, such as Oramorph or MS Contin orally every 12 hours. For example, 30 mg/d of immediate release morphine can be changed to MS Contin 15 mg BID. Immediate release morphine (in dosages of 10-30% of total daily dose Q 2-4 hours) should then be added for breakthrough pain. Conversion tables should be used when changing from one opioid to another. Methadone is also a very effective drug, and is very inexpensive. Because dosing is not linear (the conversion ratio between morphine and methadone decreases as the morphine dose increases), consultation with the Patient Care Manager or Medical Director is necessary before using methadone. A specific methadone conversion table is available.

For intractable pain, begin a PCA morphine drip for more rapid titration and pain control. Remember, 1 mg of IV morphine is roughly equivalent to 3 mg of oral morphine and 1 mg of hydromorphone is equivalent to 5 mg of IV morphine. Consultation with the Patient Care Manager and/or the Medical Director should be done before instituting infusion therapy.

C. Table of Commonly Used Opioids - Always Order "Generic" if available:

Generic Name	Brand Name	Available as:	Dosing Interval
Immediate Release Morphine	MSIR	15,30 mg tabs, capsules; 10 mg/5ml solution; 5 mg IV or SQ	q 2-4 h
	Roxanol (20mg/ml)	20 mg/ml (start with 0.25-0.5 ml for 5-10 mg dose)	q 2-4 h
Sustained Release Morphine	Oramorph, MS Contin	15,30,60,100, 200 mg tabs	q 8-12 h
	Kadian	20, 50, 100 mg tabs	q 24 h
Immediate Release Oxycodone	Roxicodone OxyFast	5, 10 mg tabs 20 mg/ml liquid	q 4 h q 2-4 h
Sustained Release Oxycodone	Oxycontin	10, 20, 40, 80, 160 mg tabs	q 8-12 h
Sustained Release Fentanyl Patch*	Duragesic	25, 50, 75, 100 mcg patches (25 mcg patch is roughly equivalent to 60 mg/d of morphine)	q 72 h
Hydro-morphone	Dilaudid	2, 4, 8 mg tabs, 3 mg supps	q 4 h
Methadone	Dolophine	5, 10 mg tabs	q 8-12 h


*Fentanyl Patch is not useful in acute pain as the patch takes up to 16-24 hours for full effect. The patch is difficult to titrate for rapid pain relief. It may be useful for patients unable to take regular oral dosing (e.g., severe dysphagia, stupor or coma, GI absorption problems). The patch requires sufficient subcutaneous tissue for absorption, and will not be predictably effective in the emaciated patient.

D. Routes of Administration

1. Oral
1. advantages: Preferred Route,
   allows greater patient mobility, convenience and satisfaction; drug levels peak in 1-2 hrs.; steady state reasonably maintained; can be administered via feeding tube when crushed; can generally be given even if patient is NPO (with small amount of fluid); most cost effective route; sublingual and liquid forms of morphine (Roxanol) and lorazepam (Ativan Intensol) available and are absorbed via the oral mucosa.

   Small immediate release tablets can be crushed and placed in the buccal space.

2. disadvantages: may be poorly absorbed if major problems with bowel motility or bowel mucosal edema

   Long acting opioids cannot be crushed, broken or chewed

2. Rectal
1. advantages:effective in patients who are NPO (including meds), or are nauseated
   avoids need for parenteral administration of meds duration of action generally 4-6 hrs available for morphine, oxymorphone (immediate release and long acting), dilaudid, methadone generally equa-analgesic with oral doses, although may be more potent because the drug bypasses the liver (avoids first pass effect)

2. disadvantages:frequent rectal dosing uncomfortable, often objectionable to family
3. Transdermal
1. advantages: non-invasive, easy to use, well accepted by patients effect generally lasts 48-72 hrs
2. disadvantages: costly difficult to quickly titrate doses requires subcutaneous tissue for absorption, very uneven effectiveness in cachectic patients fever speeds rate of absorption, sweat and hairy areas limit rate of absorption does not take full effect for ? 16 hrs.
4. Parenteral (IV or subcutaneous)
1. advantages: allows for rapid titration of pain medications and calculation of appropriate oral conversion dosages after 24 – 48 hrs subcutaneous route can deliver adequate volumes of medications, but does not have risk of central line infection, and requires sub cut needle replacement less frequently than an IV line (usually weekly) can be administered wherever patient resides
2. disadvantages: expensive route of medication delivery requires patient to be connected to pump, limiting mobility, involves pain related to needle sticks
5. Intramuscular Not generally used in chronic pain management

E. Additional Pain Management Information:

Anticipate constipation in any patient taking opioids. Patients will not develop tolerance to this side effect, and will usually need peristaltic agents on a regular basis (Pericolace). See section G: Constipation management.

As long as there is a patent GI tract, the oral route of medication administration is preferred.

There is no ceiling dose with opioids (except fentanyl which has a maximum recommended dose of 300 mcg/hr). Some patients, particularly younger patients or patients with a history of alcohol abuse, may need large quantities for adequate pain control.

Respiratory depression rarely occurs except in opioid-naive patients who are given excessive initial doses. Patients with severe pulmonary disease will often die because of disease progression, and not from the depressant effects of carefully titrated opioids.

When changing from IM/IV routes to oral, or from one medication to another, it is essential to calculate total daily morphine equivalent doses and convert to equivalent dosages.?

Opioid Titration: Inadequate pain relief, is characterized by pain at the end of the opioid dosing interval, or if a patient requires more than 4 or more doses of breakthrough immediate release opioids/ 24 h. Management of the problem requires opioid tritration; titrate up based on pain intensity:

If patients are receiving short acting opiods only: for moderate pain increase the q 2-4 h dose by 50%. After 24hrs calculate the total 24 hour opioid requirement, divide by 2 and provide as a long acting opioid q12h.

For severe pain, increase q2-4 h dose by 100%. After 24hrs calculate the total 24 hour opioid requirement, divide by 2 and provide as a long acting opioid q12h.

If patient is truly allergic to morphine, which is rare, try fentanyl or oxycodone.

Avoid IM injections; these are painful with poor absorption.?

Avoid meperidine (Demerol) because of short duration of action, toxic metabolites, and expensive oral forms.

Avoid use of mixed agonist and antagonist medication such as pentazocine (Talwin), butorphanol (Stadol) and nalbuphine (Nubain). These medications have a ceiling effect and cannot be used with other opioids.

F. Adjuvant analgesics

For neuropathic pain (burning, shooting pain in a neurologically abnormal area), the following are useful in addition to non-steroidals and opioids :

1. Tricyclic antidepressants:
   Amitriptyline (Elavil) is commonly used, although nortriptyline (Pamelor) may be better tolerated in the elderly. Start with 10 to 25 mg qhs or BID. Titrate carefully to 150 mg daily in divided dosages. Expect initial response in one to two weeks but peak effect may take six to eight weeks.
2. Anticonvulsants:
   Carbamazipine (Tegretol) 100-200 mg PO q6h or Dilantin (brand only recommended) 300 mg PO qHS
3. For pain due to tumor or CNS edema (nerve compression pain):
   Corticosteroids:
   Prednisone (generic) 10-30 mg PO qd –BID or Dexamethasone 4-8 mg PO TID. Higher doses are used in cord compression and pain emergencies.

For somatic pain (bone, soft tissue, arthritis):

1. Nonsteroidals, for example, ibuprofen (generic) 400-800 mg TID with food. Titrate to the maximum daily recommended dose or side effects. When changing NSAIDS, change to agents in a different chemical class. Consider celecoxib (Celebrex) 100-200 mg qd for patients with history of ulcer disease or GI intolerance to other NSAIDs.

For visceral or colicky abdominal pain:

1. Antispasmodics:
   Hyoscyamine (Levsin) 0.125 mg AC, HS or scopalamine patch 1.5 mg/72 h.

G. Constipation management:

Because of immobility, decreased oral intake, and regular use of opioids, constipation is a common problem for the hospice patient. An ounce of prevention really is worth a pound of cure! The following interventions are commonly recommended:

To prevent constipation:

Increase fluid intake to 4 eight oz. servings whenever possible.

Increase dietary intake of fiber (prunes, bran, fruit) to enhance bowel motility.

Use bulk agents, e.g. Metamucil, on a regular basis, but only if the patient is ambulatory and well-hydrated.

Use stool softeners with peristaltic stimulant (Senekot-S) on a daily basis when using opioids. A rough guide: use one Senekot-S for every 15 mg morphine or equivalent; use 4 Senekot-S for every 25 mcg of Duragesic patch.

Sorbitol or lactulose (1-8 Tbsp/d) may be a useful adjunct if the patient is taking fluids, and is not responding to peristaltic stimulants.

To treat constipation (which is no BM for 2-4 days):

Always check for fecal impaction; if present, use manual disimpaction and/or oil retention enema.

Begin Dulcolax suppositories, Fleet’s enema, tap water enemas, or mineral oil 30-60 cc 1-2 times/day. Use a "push/pull" approach using oral and rectal measures to get and to keep bowels moving.

Institute a regular schedule of stimulants after bowel movements are re-established.