California Physician Ebook Continuing Education

___________________________________________ Palliative Care and Pain Management at the End of Life

DECISION PATHWAY FOR PAIN MANAGEMENT

Screen for presence of pain at regular intervals

Pain present?

YES

- Rapidly titrate short-acting opioids. - Closely monitor analgesic response and side eects until resolution of pain crisis. - If signicant anxiety related to pain, administer opioids prior to sedating anxiolytics.

Patient in pain crisis?

YES

Comprehensive Pain Assessment

Patient currently on opioids?

YES

Calculate previous total 24 hour opioid use Determine if patient has opioid-induced neurotoxity (OIN)

Pain goals met?

YES

Pain goals met?

YES

Prescribe short-acting opioids on an as-needed basis, every 2 to 4 hrs. Choose from short acting weak or low doses of stronger opioids. In some patients, extended-release opioids may be used at low doses.

If no evidence of OIN: Increase existing opioid dose: by 25% to 50% of total daily opioid dose OR equal to the total breakthrough opioids used in previous 24 hours. If evidence of OIN: Opioid Rotation is indicated. Side effects may require specific interventions.

If no evidence of OIN: Continue current opioid regimen: May consider changing short- acting opioids to extended- release opioids for patient convenience. If evidence of OIN: Opioid rotation or dose reduction is indicated: May reduce opioids by 25% to 50% if OIN features. For all others, opioid rotation is preferred. Side effects may require specific interventions.

Fentanyl patches usually not recommended for opioid-naïve patients.

Continue current care plans, which may include use of non-opioid analgesics. In some patients, may consider use of short-acting opioids for breakthrough pain. Educate patients to report if pain goals not met.

For all patients: • Short-acting opioids for breakthrough pain should be made available as 10% to 15% of daily opioid dose, every 2 to 4 hours as needed. • Consider using appropriate adjuvants, complementary therapies, and psychosocial support, as appropriate. • Bowel regimen should be instituted in all patients, unless contraindicated.

Source: [223] Reprinted, with permission from Dalal S, Bruera E. Assessment and management of pain in the terminally ill. Prim Care Clin Office Pract. 2011;38:195-223. Figure 7

MDCA1525