This interactive New Jersey Physician Ebook contains 15 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
New Jersey Continuing Medical Education
NEW JERSEY MEDICAL LICENSURE PROGRAM
MANDATORY TRAINING REQUIRED FOR NEW JERSEY LICENSE RENEWAL ENCLOSED PROGRAM SATISFIES: • 1 CREDIT OPIOIDS • 2 CREDITS END-OF-LIFE • 1 CREDIT IMPLICIT AND EXPLICIT BIAS
INCLUDES: DEA’s New One-time MATE Requirement
InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™ MIPS MOC STATE LICENSURE
CME DEADLINE: 7/1/2025
AVAILABLE ONLINE AT: NJ.CME.EDU
NEW JERSEY PHYSICIAN
MANDATORY CME REQUIRED FOR NEW JERSEY LICENSE RENEWAL
Dear Colleagues,
Effective June 27, 2023, renewing DEA-registered practitioners must complete eight (8) hours of one-time training on the treatment and management of patients with opioid or substance use disorders.
As a condition of biennial renewal, the New Jersey State Board of Medical Examiners requires physicians (MD/DO) to complete one (1) credit hour of continuing medical education on prescription opioid drugs, including: responsible prescribing practices, alternatives to opioids for managing treatment of pain, and the risks & signs of opioid abuse, addiction, and diversion; two (2) credit hours on end-of-life care, unless exempt; and for those who provide perinatal care, one (1) credit hour on implicit and explicit bias. The InforMed New Jersey Medical Licensure Program is designed to streamline the education requirements of the New Jersey State Board of Medical Examiners by offering your state-mandated requirements in one optimized learning program. We have also included eight (8) credit hours on the DEA’s new one-time MATE Act requirement.
To complete the program online, visit BOOK.CME.EDU , enter the book code MDNJ1525 in the box then click GO .
Thank you for choosing lnforMed as your CME provider. We strive to create a high quality, streamlined program for our colleagues. Please contact us with any questions, concerns, or suggestions.
Best Regards,
The lnforMed CME Team
New Jersey State Board of Medical Examiners | P.O. Box 183 Trenton, New Jersey 08625 | (609) 826-7100
We are a nationally accredited CME provider. For all board-related inquiries please contact:
1-800-237-6999
BOOK CODE: MDNJ1525
BOOK.CME.EDU
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What’s Inside
01
ASSESSMENT AND MANAGEMENT OF PAIN AT THE END OF LIFE COURSE ONE | 2 CREDITS SATISFIES 2 CREDIT HOUR REQUIREMENT ON END-OF-LIFE CARE
Because pain is frequently encountered in the palliative and hospice care environments, a knowledge of appropriate diagnosis and alleviation is vital to all members of the interdisciplinary team. A comprehensive discussion of these topics will provide the knowledge base necessary for all members of the interprofessional team to better understand the varied needs of their patients during the end-of-life period and to be better equipped to address those needs. DEVELOPING A SAFE OPIOID TREATMENT PLAN FOR MANAGING CHRONIC PAIN COURSE TWO | 1 CREDIT SATISFIES 1 CREDIT HOUR REQUIREMENT ON OPIOIDS Healthcare professionals should know best clinical practices in opioid prescribing, including the associated risks of opioids, approaches to the assessment of pain and function, and pain management modalities. Patients with moderate-to-severe chronic pain who have been assessed and treated, over a period of time, with non-opioid pharmacologic or nonpharmacologic pain therapy without adequate pain relief are considered to be candidates for a trial of opioid therapy. The treatment plan should always be individualized for the patient and begun as a trial before embarking on a definitive course of treatment.
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22
MATERNAL HEALTH DISPARITIES COURSE THREE | 4 CREDITS SATISFIES 1 CREDIT HOUR REQUIREMENT ON IMPLICIT AND EXPLICIT BIAS
There is no question that maternal health disparities are a significant problem in the United States. Inequalities have been noted associated with many factors, including education level, literacy, and socioeconomic status. However, the greatest disparities have been noted among racial/ethnic minority women and have been linked to explicit and implicit biases in healthcare providers and systems. It is of the utmost importance that those working in health care and caring for patients in the peripartum and postpartum period are committed on lowering the morbidity and mortality rates of all mothers of color. Promoting equity and cultural competence, effectively addressing modifiable risk factors, improving communication and monitoring, and engaging in regular training are needed to improve these maternal health disparities. SUBSTANCE USE DISORDERS AND PAIN MANAGEMENT: MATE ACT TRAINING COURSE FOUR | 8 CREDITS SATISFIES THE DEA’S NEW ONE-TIME MATE REQUIREMENT Substance use disorders continue to be an important health issue in the United States and can lead to significant problems in all aspects of a person’s life. For DEA-registered practitioners, fulfill your DEA opioid training requirement and strengthen your expertise on appropriate assessment and management of substance use with this course. In addition, the presence of substance use disorders can complicate the treatment or management of comorbid medical conditions. Given the ongoing prescription and illicit opioid use and overdose epidemic in the United States and the widespread incidence of chronic pain, opioid prescribing and optimum safe pain management is a public health concern. All clinicians should have good knowledge of the available options for substance use disorder treatment and for safe opioid prescribing and dispensing.
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LEARNER RECORDS: ANSWER SHEET & EVALUATION REQUIRED TO RECEIVE CREDIT
iii
MOC/MIPS CREDIT INFORMATION
Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABOHNS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs
American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®
ABA
ABIM
American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABS
American Board of Surgery’s Continuous Certification program.
ABPath
American Board of Pathology’s Continuing Certification Program
ABP
American Board of Pediatrics’ Maintenance of Certification (MOC) program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits T M 2 AMA PRA Category 1 Credits TM 1 AMA PRA Category 1 Credits TM 4 AMA PRA Category 1 Credits TM 8 AMA PRA Category 1 Credits TM
Activity Title
ABA
ABIM ABS
ABPath
ABP
2 Credits LL
2 Credits MK
2 Credits SA + AC
2 Credits LL
Assessment and Management of Pain at the End of Life Developing a Safe Opioid Treatment Plan for Managing Chronic Pain
-
1 Credit LL
1 Credit MK
1 Credit SA + AC
1 Credit LL
1 Credit LL+SA
4 Credits MK 8 Credits MK
4 Credits SA + AC 8 Credits SA + AC
4 Credits LL 8 Credits LL
4 Credits LL+SA 8 Credits LL+SA
-
Maternal Health Disparities
8 Credits LL
Substance Use Disorders and Pain Management: MATE Act Training
Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, AC = Accredited CME
DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.
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How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the self-assessment questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.
ONLINE
FASTEST AND EASIEST!
• Go to BOOK.CME.EDU and enter code MDNJ1525 in the book code box, then click GO. • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your self-assessment. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.
Enter book code
MDNJ1525
GO
IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.
Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899
BY MAIL
Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
Program Options
Price
Option
Code
Credits
ENTIRE PROGRAM • Assessment and Management of Pain at the End of Life • Developing a Safe Opioid Treatment Plan for Managing Chronic Pain • Maternal Health Disparities • Substance Use Disorders and Pain Management: MATE Act Training
$127
MDNJ1525 15 Credits
$15
Assessment and Management of Pain at the End of Life
MDNJ02EL 2 Credits
$15
Developing a Safe Opioid Treatment Plan for Managing Chronic Pain
MDNJ01SO 1 Credit
$28
Maternal Health Disparities
MDNJ04MH 4 Credits
$69
Substance Use Disorders and Pain Management: MATE Act Training
MDNJ08SU 8 Credits
1-800-237-6999
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____________________________________________ Assessment and Management of Pain at the End of Life MDNJ02EL— 2 CREDITS R elease D ate : 11/01/24 E xpiration D ate : 10/31/27 Assessment and Management of Pain at the End of Life
In addition to receiving AMA PRA Category 1 Credit TM , physicians participating in Maintenance of Certification will receive the following points appropriate to their certifying board: 2 ABIM MOC Points, 2 ABS MOC Points, 2 ABA MOC Points, 2 ABPath Points.
Vanderbilt University Department of Medicine. Over a career span of 40 years, Dr. Leonard conducted an active practice of general internal medicine and an inpatient consulting practice of infectious diseases. Faculty Disclosure Contributing faculty, John M. Leonard, MD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planners John V. Jurica, MD, MPH Mary Franks, MSN, APRN, FNP-C Senior Director of Development and Academic Affairs Sarah Campbell Division Planners/Director Disclosure The division planners and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Designations of Credit NetCE designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of this CME activity, which includes participation in the evaluation component, enables the par- ticipant to earn up to 2 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equiva- lent to the amount of CME credits claimed for the activity.
HOW TO RECEIVE CREDIT
• Read the enclosed course. • Complete the final examination questions at the end. A score of 70% is required. • Return your customer information/answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU.
Audience This course is designed for physicians, physician assistants, nurses, social workers, and other members of the healthcare team seeking to enhance their knowledge of pain management. Course Objective Because pain is frequently encountered in the palliative and hospice care environments, a knowledge of appropriate diagnosis and alleviation is vital to all members of the inter- disciplinary team. The purpose of this course is to provide an overview of the assessment and management of pain in the end of life, focusing on the components integral to providing optimum care. Learning Outcomes
Upon completion of this course, you should be able to: 1. Describe the etiology of pain at the end of life and issues in effective pain management. 2. Assess pain accurately through use of clinical tools and other strategies, including the use of an interpreter. 3. Select appropriate pharmacologic and/or nonpharmacologic therapies to manage pain in patients during the end-of-life period. F aculty
John M. Leonard, MD, Professor of Medicine Emeritus, Vanderbilt University School of Medicine, completed his post- graduate clinical training at the Yale and Vanderbilt University Medical Centers before joining the Vanderbilt faculty in 1974. He is a clinician-educator and for many years served as director of residency training and student educational programs for the
1 Mention of commercial products does not indicate endorsement.
MDNJ1525
Assessment and Management of Pain at the End of Life _ ___________________________________________
About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distrib- uting or providing access to this activity to learners.
It is the CME activity provider’s responsibility to submit par- ticipant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment requirements of the American Board of Surgery’s Continu- ous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anesthesiology’s ® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certi- fication in Anesthesiology Program ® (MOCA ® ), known as MOCA 2.0 ® . Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program ® and MOCA ® are registered cer- tification marks of the American Board of Anesthesiology ® . MOCA 2.0 ® is a trademark of the American Board of Anes- thesiology ® . This activity has been designated for 2 Lifelong Learning (Part II) credits for the American Board of Pathology Con- tinuing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACC- ME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program.
Sections marked with this symbol include evidence-based practice recommendations. The level of evidence and/or strength of recommendation, as provided by the evidence-based source, are also included
so you may determine the validity or relevance of the information. These sections may be used in conjunction with the course material for better application to your daily practice.
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Encouraging patients to be honest about pain and other symptoms is also vital. Clinicians should ensure that patients understand that pain is multidimensional and emphasize the importance of talking to a member of the healthcare team about possible causes of pain, such as emotional or spiritual distress. The healthcare team and patient should explore psy- chosocial and cultural factors that may affect self-reporting of pain, such as concern about the cost of medication. Clinicians’ attitudes, beliefs, and experiences also influence pain management, with addiction, tolerance, side effects, and regulations being the most important concerns [1; 8; 11; 13; 14; 15]. A lack of appropriate education and training in the assessment and management of pain has been noted to be a substantial contributor to ineffective pain management [11; 13; 15; 16]. As a result, many clinicians, especially primary care physicians, do not feel confident about their ability to manage pain in their patients [11; 13]. Cultural and demographic factors may also contribute to lack of effective pain management. Expression of pain and the use of pain medication differ across cultures. For example, His- panic and Filipino patients have been shown to be reluctant to report pain because of fear of side effects or addiction [17]. Even when effective opioids have been prescribed, access may be difficult, as inadequate supplies of opioids are more likely in pharmacies in primarily nonwhite neighborhoods [18]. Communication with patients regarding level of pain is a vital aspect of caring for patients in the end of life. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required. ETIOLOGY The prevalence of pain at the end of life has been reported to range from 8% to 96%, occurring at higher rates among people with cancer than among adults with other life-limiting diseases [19; 20]. Pain can be caused by a multitude of factors and is usually multidimensional, with pain frequently being exacerbated by other physical symptoms and by psychosocial factors, such as anxiety or depression [8]. ASSESSMENT Pain should be assessed routinely, and frequent assessment has become the standard of care [8]. Pain is a subjective experience, and as such, the patient’s self-report of pain is the most reliable indicator. Research has shown that pain is underestimated by healthcare professionals and overestimated by family mem- bers [8; 21]. Therefore, it is essential to obtain a pain history directly from the patient, when possible, as a first step toward determining the cause of the pain and selecting appropriate treatment strategies.
INTRODUCTION Unrelieved pain is the greatest fear among people with a life- limiting disease, and the need for an increased understanding of effective pain management is well-documented [1]. Although experts have noted that 75% to 90% of end-of-life pain can be managed effectively, rates of pain are high, even among people receiving palliative care [1; 2; 3; 4; 5; 6; 7; 8; 9; 10].
ISSUES IN EFFECTIVE PAIN MANAGEMENT
The inadequate management of pain is the result of several factors related to both patients and clinicians. In a survey of oncologists, patient reluctance to take opioids or to report pain were two of the most important barriers to effective pain relief [11]. This reluctance is related to a variety of attitudes and beliefs [1; 11]: • Fear of addiction to opioids • Worry that if pain is treated early, there will be no options for treatment of future pain • Anxiety about unpleasant side effects from pain medications • Fear that increasing pain means that the disease is getting worse • Desire to be a “good” patient • Concern about the high cost of medications Education and open communication are the keys to overcom- ing these barriers. Every member of the healthcare team should reinforce accurate information about pain management with patients and families. The clinician should initiate conversa- tions about pain management, especially regarding the use of opioids, as few patients will raise the issue themselves or even express their concerns unless they are specifically asked [12]. It is important to acknowledge patients’ fears individually and provide information to help them differentiate fact from fiction. For example, when discussing opioids with a patient who fears addiction, the clinician should explain that the risk of addiction is low [1]. It is also helpful to note the difference between addiction and physical dependence. There are several other ways clinicians can allay patients’ fears about pain medication: • Assure patients that the availability of pain relievers cannot be exhausted; there will always be medications if pain becomes more severe. • Acknowledge that side effects may occur but emphasize that they can be managed promptly and safely and that some side effects will abate over time. • Explain that pain and severity of disease are not neces- sarily related.
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When the patient is unable to communicate verbally, other strategies must be used to determine the characteristics of the pain, as will be discussed. Questions should be asked to elicit descriptions of the pain characteristics, including its location, distribution, quality, temporal aspect, and intensity. In addition, the patient should be asked about aggravating or alleviating factors. Pain is often felt in more than one area, and physicians should attempt to discern if the pain is focal, multifocal, or generalized. Focal or multifocal pain usually indicates an underlying tissue injury or lesion, whereas generalized pain could be associated with damage to the central nervous system. Pain can also be referred, usually an indicator of visceral pain. The quality of the pain refers to the sensation experienced by the patient, and it often suggests the pathophysiology of the pain [8]. Pain that is well localized and described as ach- ing, throbbing, sharp, or pressure-like is most likely somatic nociceptive pain. This type of pain is usually related to dam- age to bones and soft tissues. Diffuse pain that is described as squeezing, cramping, or gnawing is usually visceral nociceptive pain. Pain that is described as burning, tingling, shooting, or shock-like is neuropathic pain, which is generally a result of a lesion affecting the nervous system. Temporal aspects of pain refer to its onset: acute, chronic, or “breakthrough.” A recent onset characterizes acute pain, and there are accompanying signs of generalized hyperactivity of the sympathetic nervous system (diaphoresis and increased blood pressure and heart rate). Acute pain usually has an identifiable, precipitating cause, and appropriate treatment with analgesic agents will relieve the pain. When acute pain develops over several days with increasing intensity, it is said to be subacute. Episodic, or intermittent, pain occurs during defined periods of time, on a regular or irregular basis. Chronic pain is defined as pain that persists for at least three months beyond the usual course of an acute illness or injury. Such pain is not accompanied by overt pain behaviors (grimacing, moaning) or evidence of sympathetic hyperactivity. “Breakthrough” is the term used to describe transitory exac- erbations of severe pain over a baseline of moderate pain [22]. Breakthrough pain can be incident pain or pain that is precipitated by a voluntary act (such as movement or cough- ing) or can occur without a precipitating event. Breakthrough pain occurs in as many as 90% of people with cancer or in hospice settings and is often a consequence of inadequate pain management [1]. Documentation of pain intensity is key, as several treatment decisions depend on the intensity of the pain. For example, severe, intense pain requires urgent relief, which affects the choice of drug and the route of administration [8; 23]. The numeric rating scale is the tool used most often to assess pain; with this tool, patients rate pain on a scale of 0 to 10 [8]. Visual analogue scales (patients rate pain on a line from 0 to 10) and verbal rating scales, which enable the patient to describe the pain as “mild,” “moderate,” or “severe,” have also been found
to be effective. Some patients, however, may have difficulty rating pain using even the simple scales. In an unpublished study involving 11 adults with cancer, the Wong-Baker FACES scale, developed for use in the pediatric setting, was found to be the easiest to use among three pain assessment tools that include faces to assess pain [24]. Functional assessment is important. The healthcare team should observe the patient to see how pain limits movements and should ask the patient or family how the pain interferes with normal activities. Determining functional limitations can help enhance patient compliance in reporting pain and adhering to pain-relieving measures, as clinicians can discuss compliance in terms of achieving established functional goals [12]. The Memorial Pain Assessment Card can be used to evaluate both the severity of pain and the effect of pain on function [8; 25]. Physical examination can be valuable in determining an under- lying cause of pain. Examination of painful areas can detect evidence of trauma, skin breakdown, or changes in osseous structures. Auscultation can detect abnormal breath or bowel sounds; percussion can detect fluid accumulation; and palpa- tion can reveal tenderness. A neurologic examination should also be carried out to evaluate sensory and/or motor loss and changes in reflexes. During the examination, the clinician should watch closely for nonverbal cues that suggest pain, such as moaning, grimacing, and protective movements. These cues are especially important when examining patients who are unable to verbally communicate about pain. MANAGEMENT Strong evidence supports pain management approaches for people with cancer, but the evidence base for management of pain in people with other life-limiting diseases is weak [2; 4; 26; 27; 28; 29; 30]. Effective pain management involves a multidimensional approach involving pharmacologic and nonpharmacologic interventions that are individualized to the patient’s specific situation [8]. PHARMACOLOGIC INTERVENTIONS The WHO analgesic ladder, introduced in 1986 and dissemi- nated worldwide, remains recognized as a useful educational tool but not as a strict protocol for the treatment of pain. It is intended to be used only as a general guide to pain management [31]. The three-step analgesic ladder designates the type of analgesic agent based on the severity of pain ( Figure 1 ) [31]. Step 1 of the WHO ladder involves the use of nonopioid analgesics, with or without an adjuvant (co- analgesic) agent, for mild pain (pain that is rated 1 to 3 on a 10-point scale). Step 2 treatment, recommended for moderate pain (score of 4 to 6), calls for a weak opioid, which may be used in combination with a step 1 nonopioid analgesic for unrelieved pain. Step 3 treatment is reserved for severe pain (score of 7 to 10) or pain that persists after Step 2 treatment.
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THE WORLD HEALTH ORGANIZATION’S THREE-STEP LADDER OF ANALGESIA
Step 3 Strong opioids +/- Non-opioids +/- Adjuvant analgesics
Severe pain (7-10 on a 10-point scale)
Step 2 Weak opioids +/- Non-opioids +/- Adjuvant analgesics
Mild-to-moderate pain (4-6 on a 10-point scale)
Mild pain (1-3 on a 10-point scale)
Step 1 Non-opioids +/- Adjuvant analgesics
Source: [31]
Figure 1
Strong opioids are the optimum choice of drug at Step 3. At any step, nonopioids and/or adjuvant drugs may be helpful. Some consider this model to be outdated and/or simplistic, but most agree that it remains foundational. It can be modi- fied or revised, as needed, to apply more accurately to different patient populations. The WHO ladder is also accompanied by five guiding prin- ciples [31]: • Reduce pain to levels that allow an acceptable quality of life. • Global assessment of the patient
lower doses in people with a history of alcohol abuse or renal or hepatic insufficiency [8]. NSAIDs are most effective for pain associated with inflam- mation. Among the commonly used NSAIDs are ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn), and indometha- cin (Indocin). There are several classes of NSAIDs, and the response differs among patients; trials of drugs for an individ- ual patient may be necessary to determine which drug is most effective [33]. NSAIDs inhibit platelet aggregation, increasing the risk of bleeding, and also can damage the mucosal lining of the stomach, leading to gastrointestinal bleeding. There is a ceiling effect to the nonopioid analgesics; that is, there is a dose beyond which there is no further analgesic effect. In addition, many side effects of nonopioids can be severe and may limit their use or dosing. Moderate pain (Step 2) has often been treated with analgesic agents that are combinations of acetaminophen and an opioid, such as codeine, oxycodone, or hydrocodone. However, it is now recommended that these combination drugs be avoided, as limits on the maximum dose of acetaminophen limits the use of a combination drug [8; 34]. Individual drugs in combi- nation is preferred, allowing for increases in the dose of the opioid without increasing the dose of the co-analgesic. Strong opioids are used for severe pain (Step 3). Guidelines suggest that the most appropriate opioid dose is the dose required to relieve the patient’s pain throughout the dosing interval without causing unmanageable side effects [4; 8; 26; 28; 30; 34; 36]. Morphine, buprenorphine, oxycodone, hydro- morphone, fentanyl, and methadone are the most widely used Step 3 opioids in the United States [35]. Unlike nonopioids, opioids do not have a ceiling effect, and the dose can be titrated until pain is relieved or side effects become unmanageable. For an opioid-naïve patient or a patient who has been receiving low doses of a weak opioid, the initial dose of a Step 3 opioid
should guide treatment, recognizing that individuals experience and express pain differently. • The safety of patients, carers, healthcare providers, communities, and society must be assured. • A pain management plan includes pharmacologic treatments and may include psychosocial and spiritual care. • Analgesics, including opioids, must be accessible: both available and affordable.
The pharmacologic treatment of pain involves selecting the right drug(s) at the right dose, frequency, and route, and managing side effects [8]. Nonopioid analgesics, such as aspirin, acetaminophen (Tyle- nol), and nonsteroidal anti-inflammatory drugs (NSAIDs), are primarily used for mild pain (Step 1 of the WHO ladder) and may also be helpful as coanalgesics at Steps 2 and 3. Acet- aminophen is among the safest of analgesic agents, but it has essentially no anti-inflammatory effect. Toxicity is a concern at high doses, and the maximum recommended dose is 3–4 g per day [8]. Acetaminophen should be avoided or given at
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should be low, and, if pain persists, the dose may be titrated up daily until pain is controlled. Opioid-naïve patients are those who are not receiving opioid analgesic daily and therefore have not developed significant tolerance. Opioid-tolerant patients are those who have been taking an opioid analgesic daily for at least one week. The FDA identifies tolerance as receiving at least 60 mg of morphine daily, 30 mg of oral oxycodone daily, 8 mg of oral hydromorphone daily, or an equianalgesic dose of another opioid for one week or longer [30]. Typical starting doses for patients who are opioid-naïve have been noted, but these doses should be used only as a guide, and the initial dose, as well as titrated dosing, should be done on an individual basis ( Table 1 ). The most serious potential adverse effect following initiation of opioids for treatment of pain is oversedation followed by respiratory depression. To mitigate this risk, clinicians should discuss the role of naloxone administration by caregivers in the event of sedation/respiratory depression and make naloxone available as indicated or as required by local regulations [30]. When initiating morphine, or any opioid agent for treatment of moderate/severe pain, the prescribing clinician should consider lower starting dose titration in frail or older patients and in any patient with renal insufficiency (reduced creatinine clearance). More than one route of opioid administration will be needed by many patients during end-of-life care, but in general, opioids should be given orally, as this route is the most convenient and least expensive. The transdermal route is preferred to the parenteral route, although dosing with a transdermal patch is less flexible and may not be appropriate for patients with unstable pain [8]. Intramuscular injections should be avoided
because injections are painful, drug absorption is unreliable, and the time to peak concentration is long [8]. Morphine is considered to be the first-line treatment for a Step 3 opioid [34]. Morphine is available in both immediate-release and sustained-release forms, and the latter form can enhance patient compliance. The sustained-release tablets should not be cut, crushed, or chewed, as this counteracts the sustained- release properties. Morphine should be avoided in patients with severe renal failure [28]. Buprenorphine (Butrans) has the general structure of mor- phine but differs from it in several ways [35]. The transdermal formulation of the drug was approved in 2010 for moderate-to- severe chronic pain in patients requiring an around-the-clock opioid for an extended period [8]. It may be used for people with renal impairment but is contraindicated in patients who have substantial respiratory depression [35; 37]. The sustained-release form of oxycodone (OxyContin) has been shown to be as safe and effective as morphine for cancer- related pain, and it may be associated with less common side effects, especially hallucinations and delirium [40]. Oxycodone is also available in an immediate-release form (Roxicodone). Oxycodone should be used in people with advanced chronic kidney disease only if alternative options are not available [28]. If the drug must be used, the intervals between doses should be increased, and the patient should be monitored closely [28]. Hydromorphone and fentanyl are the most potent opioids; neither drug should be given to an opioid-naïve patient. Hydromorphone, which is four times as potent as morphine, is available in immediate- and extended-release forms [41].
OPIOIDS FOR THE MANAGEMENT OF PAIN IN ADULTS a
Typical Starting Dose b
Drug
Onset of Action 30 to 60 minutes 10 to 20 minutes
Duration of Action
Codeine
15–60 mg 2.5–10 mg 15–30 mg
4 to 6 hours 4 to 8 hours 3 to 6 hours 3 to 4 hours 8 to 12 hours 4 to 5 hours 4 to 6 hours 4 to 6 hours
Hydrocodone
Morphine, immediate release
15 to 30 minutes (oral) 5 to 10 minutes (IV)
Oxycodone, immediate release Oxymorphone, sustained release
5–10 mg
10 to 30 minutes 5 to 10 minutes 15 to 30 minutes 30 to 60 minutes
10 mg
Hydromorphone
2–4 mg 5–10 mg
Methadone Tapentadol
50–100 mg 50–100 mg 100–200 mcg
<60 minutes
Tapentadol, extended release
—
—
Fentanyl (buccal tablet)
5 to 15 minutes 12 to 18 hours
2 to 4 hours
Fentanyl (transdermal patch)
25 mcg/hour (worn for 3 days) 5–10 mcg/hour (worn for 7 days)
48 to 72 hours
Buprenorphine (transdermal patch)
—
—
a All information is given for oral formulations unless otherwise specified. b Doses given are guidelines for opioid-naïve patients; actual doses should be determined on an individual basis. Source: [4; 8; 30; 37; 38; 39]
Table 1
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____________________________________________ Assessment and Management of Pain at the End of Life
Fentanyl is the strongest opioid (approximately 80 times the potency of morphine) and is available as a transdermal drug- delivery system (Duragesic; Ionsys); a buccal film (Onsolis) and tablet (Fentora); a nasal spray (Lazanda); a sublingual spray (Subsys); a sublingual tablet (Abstral); and a lozenge (Actiq) [37; 42]. Fentanyl preparations have a more rapid onset than other opioids given nonparenterally [8]. Because of its potency, fentanyl must be used with extreme care, as deaths have been associated with its use. Physicians must emphasize to patients and their families the importance of following prescribing information closely, and members of the healthcare team should monitor the use of the drug. Fentanyl, administered subcutaneously, is the recommended choice for patients with advanced chronic kidney disease [28]. The use of methadone to relieve pain has increased substan- tially over the past few years, moving from a second-line or third-line drug to a first-line medication for severe pain in peo- ple with life-limiting diseases [43]. A systematic review showed that methadone had efficacy similar to that of morphine [44]. However, the authors’ conclusions were based on low-quality evidence. Other opioids (e.g., morphine, fentanyl) are easier to manage but may be more expensive than methadone in many economies [44]. Physicians must be well educated about the pharmacologic properties of methadone, as the risk for serious adverse events, including death, is high when the drug is not administered appropriately [44; 45]. If the dose of methadone is increased too rapidly or administered too frequently, toxic accumulation of the drug can cause respiratory depression and death. Because of the unique nature of methadone, and its long and variable half-life, extreme care must be taken when titrating the drug, and frequent and careful evaluation of the patient is required. Practitioners are advised to consult with a pain or palliative care specialist if they are unfamiliar with methadone prescribing or if individual patient considerations necessitate rapid switching to or from methadone [4]. Meperidine (Demerol) should not be used in the palliative care setting because of limited efficacy and potential for severe toxicity [12; 33]. Agonist-antagonist opioids (nalbuphine [Nubain], butorphanol [Stadol], and pentazocine [Talwin]) are not recommended for use with pure opioids, as they compete with them, leading to possible withdrawal symptoms. Tapentadol (Nucynta) is a short-acting opioid approved for moderate to severe pain in adults; an extended release formula- tion (Nucynta ER) was approved in 2011 for moderate-to-severe chronic pain when an around-the-clock opioid is needed [46].
The drug is associated with a lower incidence of adverse effects than other opioids, and it has been shown to be highly effec- tive for chronic pain conditions but has not been extensively studied in cancer-related pain or the palliative care setting [47]. A 2014 study of 123 patients that had previously received long- term analgesia for cancer-related pain showed tapentadol sig- nificantly reduced pain scores and was generally well tolerated; concomitant use of pain medications was also reduced [48]. The most appropriate option for breakthrough pain is an immediate-release opioid taken in addition to the around-the- clock regimen [8]. The fentanyl buccal tablet has been shown to be effective and safe for relieving breakthrough pain in people who are opioid tolerant [4; 49; 50]. Between January 2011 and January 2012, three forms of fentanyl were approved for breakthrough pain in people with cancer: fentanyl sublingual tablet (Abstral), fentanyl nasal spray (Lazanda), and fentanyl sublingual spray (Subsys) [37]. Abstral and Lazanda have since been discontinued [37; 41]. As of 2021, the fentanyl lozenge (Actiq) and buccal tablet (Fentora) are also approved for break- through cancer pain [41]. For each formula, the initial dose may be repeated once if pain is not relieved adequately after 30 minutes. Patients must wait at least two hours before using the sublingual tablet, buccal film, or the nasal spray for another breakthrough pain episode; the interval is four hours for the sublingual spray, lozenge, or buccal tablet [37; 41]. When pain responds poorly to escalated doses of an opioid, other approaches should be considered, including alternative routes of administration, use of alternate opioids (termed opioid rotation or opioid switching), use of adjuvant analge- sics, and nonpharmacologic approaches. A process for opioid switching has been established; the first step is to calculate the equianalgesic dose of the new drug [4; 8; 34]. Additional care is needed when switching to methadone, and conversion ratios have been established [4]. Evidence suggests that the traditionally recommended equianalgesic doses for the fentanyl transdermal patch are subtherapeutic for patients with chronic cancer-related pain, and more aggressive approaches may be warranted [4; 8; 51]. Another approach that has been used for pain management in the cancer setting is combination opioid therapy, or the concurrent use of two strong opioids. The effectiveness of this approach has been evaluated in only two studies, and the combination was morphine and oxycodone or morphine with fentanyl or methadone [52]. The evidence to support a recommendation of combination opioid therapy is weak, and the side effects most likely outweigh the benefit [52]. Opioids are associated with many side effects, the most notable of which is constipation, occurring in nearly 100% of patients. The universality of this side effect mandates that once extended treatment with an opioid begins, prophylactic treatment with laxatives must also be initiated.
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Tolerance to other side effects, such as nausea and sedation, usually develops within three to seven days. Some patients may state that they are “allergic” to an opioid. It is important for the physician to explore what the patient experienced when the drug was taken in the past, as many patients misinterpret side effects as an allergy. True allergy to an opioid is rare [8]. Opioid rotation may also be done to reduce adverse events. According to the Institute for Clinical Systems Improvement, there needs to be shared decision-making with the patient about reducing or eliminating opioids to avoid unnecessary complications from long-term opioid use. This involves following and re-evaluating the patient closely, with dose reduction or discontinuation as needed. (https://www.icsi.org/wp-content/uploads/2021/11/ PalliativeCare_6th-Ed_2020_v2.pdf. Last accessed October 19, 2024.) Level of Evidence : Expert Opinion/Consensus Statement When opioids are prescribed, careful documentation of the patient’s history, examinations, treatments, progress, and plan of care are especially important from a legal perspective. This documentation must provide evidence that the patient is functionally better off with the medication than without [33]. In addition, physicians must note evidence of any dysfunction or abuse. Adjuvant agents are often used in conjunction with opioids and are usually considered after the use of opioids has been optimized [33]. The primary indication for these drugs is adjunctive because they can provide relief in specific situations, especially neuropathic pain. Examples of adjuvant drugs are tricyclic antidepressants, anticonvulsants, muscle relaxants, and corticosteroids ( Table 2 ) [4; 8]. A systematic review found that there was limited evidence to support the use of selective serotonin reuptake inhibitors (SSRIs) for neuropathic pain, but one serotonin-norepinephrine reuptake inhibitor, venlafaxine (Effexor), was found to be effective [53]. NONPHARMACOLOGIC INTERVENTIONS Several nonpharmacologic approaches are therapeutic comple- ments to pain-relieving medication, lessening the need for higher doses and perhaps minimizing side effects. These interventions can help decrease pain or distress that may be contributing to the pain sensation. Approaches include palliative radiotherapy, complementary/alternative methods, manipulative and body-based methods, and cognitive/behav- ioral techniques. The choice of a specific nonpharmacologic intervention is based on the patient’s preference, which, in turn, is usually based on a successful experience in the past.
Palliative radiotherapy is effective for managing cancer-related pain, especially bone metastases [2; 54; 55]. Bone metastases are the most frequent cause of cancer-related pain; 50% to 75% of patients with bone metastases will have pain and impaired mobility [54]. External-beam radiotherapy is the mainstay of treatment for pain related to bone metastases. At least some response occurs in 70% to 80% of patients, and the median duration of pain relief has been reported to be 11 to 24 weeks [54]. It takes one to four weeks for optimal therapeutic results [54; 55]. However, palliative radiotherapy has become a controversial issue. Although the benefits of palliative radiotherapy are well documented and most hospice and oncology professionals believe that palliative radiotherapy is important, this treatment approach is offered at approximately 24% of Medicare-certified freestanding hospices, with less than 3% of hospice patients being treated [56; 57; 58]. As previously noted, reimburse- ment issues present a primary barrier to the use of palliative radiotherapy [56; 57; 58]. Among other barriers are short life expectancy, transportation issues, patient inconvenience, and lack of knowledge about the benefits of palliative radiotherapy in the primary care community [55; 56; 57; 59]. One study found that more than half (54%) of people use complementary/alternative medicine therapies at the end of life [60]. The most commonly used therapies are massage, music, relaxation techniques, and acupuncture [60; 61; 62; 63; 64]. Massage, which can be broadly defined as stroking, compres- sion, or percussion, has led to significant and immediate improvement in pain in the hospice setting [65]. Both mas- sage and vibration are primarily effective for muscle spasms related to tension or nerve injury, and massage can be carried out with simultaneous application of heat or cold. Massage may be harmful for patients with coagulation abnormalities or thrombophlebitis [12]. Focused relaxation and breathing can help decrease pain by easing muscle tension. Progressive muscle relaxation, in which patients follow a sequence of tensing and relaxing muscle groups, has enabled patients to feel more in control and to experience less pain and can also help provide distraction from pain [12]. This technique should be avoided if the muscle tensing will be too painful. Acupuncture typically provides pain relief 15 to 40 minutes after stimulation. Relief seems to be related to the release of endorphins and a susceptibility to hypnosis [12]. The efficacy of acupuncture for relieving pain has not been proven, as study samples have been small. However, acupuncture has been found to be of some benefit for cancer-related pain when the therapy is given in conjunction with analgesic therapy [66]. Other nonpharmacologic interventions that have been help- ful for some patients but lack a strong evidence base include manipulative and body-based methods (such as application of cold or heat, and positioning), yoga, distraction, and music or art therapy.
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ORAL ADJUVANT ANALGESICS
Drug Class
Drug
Typical Starting Dose 100–300 mg once daily 25–75 mg twice daily 50–100 mg twice daily
Usual Effective Dose
Anticonvulsants
Gabapentin Pregabalin
300–1,200 mg (2 or 3 divided doses)
75–200 mg (3 divided doses)
Carbamazepine
300–600 mg twice daily 50–200 mg twice daily 150–600 mg twice daily 4–12 mg twice daily 50–150 mg at bedtime
Topiramate
25–50 mg daily
Oxcarbazepine
150–300 mg twice daily
Tiagabine
4 mg at bedtime
Tricyclic antidepressants
Amitriptyline Nortriptyline Desipramine Venlafaxine
10–25 mg at bedtime
Serotonin-norepinephrine reuptake inhibitors Skeletal muscle relaxants
37.5 mg daily
150–350 mg daily
Baclofen
5 mg twice daily 5 mg 3 times daily 400 mg 3 times daily
10–20 mg 2 or 3 times daily 10–20 mg 3 times daily
Cyclobenzaprine
Metaxalone
Not defined Not defined
Corticosteroids Source: [4; 8; 41]
Dexamethasone
1–2 mg
Table 2
The application of cold and heat are particularly useful for localized pain and have been found to be effective for cancer- related pain caused by bone metastases or nerve involvement, as well as for prevention of breakthrough incident pain [12]. Alternating application of heat and cold can be soothing for some patients, and it is often combined with other nonphar- macologic interventions. Cold can be applied through wraps, gel packs, ice bags, and menthol. It provides relief for pain related to skeletal muscle spasms induced by nerve injury and inflamed joints. Cold application should not be used for patients with peripheral vascular disease. Heat can be applied as dry (heating pad) or moist (hot wrap, tub of water) and should be applied for no more than 20 minutes at a time, to avoid burning the skin. Heat should not be applied to areas of decreased sensation or with inadequate vascular supply, or for patients with bleeding disorders. Changing the patient’s position in the bed or chair may help relieve pain and also helps minimize complications such as decubitus ulcers, contractures, and frozen joints. Members of the healthcare team as well as family members and other informal caregivers can help reposition the patient for comfort and also perform range-of-motion exercises. Physical and occu- pational therapists can recommend materials, such as cushions, pillows, mattresses, splints, or support devices. Hatha yoga is the branch of yoga most often used in the medi- cal context, and it has been shown to provide pain relief for patients who have osteoarthritis and carpal tunnel syndrome but it has not been studied in patients at the end of life. Yoga
may help relieve pain indirectly in some patients through its effects on reducing anxiety, increasing strength and flexibility, and enhancing breathing [67]. Yoga also helps patients feel a sense of control. Methods to provide distraction from pain come in a wide variety of methods, including reciting poetry, meditating with a calm phrase, watching television or movies, playing cards, visiting with friends, or participating in crafts. Music therapy and art therapy are also becoming more widely used as nonpharmacologic options for pain management. Listening to music has been shown to decrease the intensity of pain and reduce the amount of opioids needed, but the magnitude of the benefit was small [68]. Research suggests that art therapy contributes to a patient’s sense of well-being [69]. Creating art helps patients and families to explore thoughts and fears during the end of life. An art therapist can help the creators reflect on the implications of the art work. Art therapy is especially helpful for patients who have difficulty expressing feelings with words, for physical or emotional reasons.
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