Opioid Stewardship in Palliative Care and End of Life
Care
Stephanie Abel, PharmD, BCPS – UK HealthCare
Katrina Nickels, MD – Bluegrass Care Navigators
Disclosure of Conflicts of
Interest
– Katrina Nickels, MD and Stephanie Abel,
PharmD, BCPS have no real or apparent financial
relationships to report.
Objectives
– Distinguish between Pain Management,
Palliative Care, and End of Life care
– Discuss general best practices for
responsible opioid prescribing in
palliative care patients
Palliative
Care (PC)
Palliative Care
Interdisciplinary Model
– Spiritual
– Social Work
– Financial, community resources
– Family dynamics
– Anticipatory Education
– Care Navigation
– Advance Care Planning
– Multimodal pain management
– Acute Symptom Distress management
– End of Life Pain
End of life (EOL)
Definition from medical perspective
Hospice qualification
Prognosis
Expectations
Pain at the EOL
– Prevalence in literature ~50% - 75%
– 17 - 35% of patients experience severe or intolerable pain
in their last week of life
– Myths/misconceptions
– Palliative and hospice providers use opioids in everyone
– Palliative care clinicians rely primarily on opioids for analgesia
– Risks of opioid misuse aren’t relevant in palliative and hospice
– Opioids at EOL hasten death
– Principle of Double Effect (PDE)
Pain Manag Nurs. 2018;19(1):3-7.
BMC Palliat Care. 2020;19(1):60.
Opioids -
Indications
Medication for Opioid Use Disorder
Pain
Dyspnea Cough
Opioid Indications
KY Regulatory Environment
– KY House Bill 1
– Goal was to decrease opioid prescribing
– KAR 9:270
– Amended May 12, 2020 to allow exceptions for inpatient care,
hospice and palliative care, and cancer pain in active treatment
Palliative Care and Pain
Management
– Chronic pain pharmacologic management is the same approach, regardless of malignant or non-malignant (Multimodal analgesia, Functional Pain Goals)
– Palliative Care Interdisciplinary Team model may enhance attention to the spiritual, social, and emotional aspects of pain
Total Pain
Physical
• Caused by treatment
• Caused by illness
• Concomitant disease
Psychological
• Anxiety
• Depression
• Fear of suffering
Social
• Financial
• Loss of job
• Loss of role in family &/or social circles
• Worries about future
• Fertility & parenthood issues
Spiritual
• Anger
• Loss of faith
• Finding purpose
Ong C-K, Forbes D. BMJ. 2005;331(7516):576-576.
Pain Management Approach in PC
Marco Cascella, MD. The revised WHO analgesic ladder. StatPearls Publishing Jan 2020.
WHO
Analgesic
Ladder
Evolution
Multimodal
Approach
Optimal Pharmacotherapy
Psychological
Education
Physical Medicine /
RehabInterventional
Non-pharmacologic
Opioids and Cancer
A Disease State Overview of the Importance of
Opioid Stewardship in Palliative Pain
Management
Opioid Use and Cancer Collide in Kentucky
– 32 Kentucky counties are in
the 90th or higher
percentile of opioid
prescribing per capita
– 79 Kentucky counties are in
the 90th or higher
percentile of cancer
incidence per capita
– 26 Kentucky counties are in
both
Occurrence of OUD in
Patients with Cancer
– Not well evaluated/documented
– Same risk as general population?
– General incidence of any SUD is ~9%
– Cancer pain is NOT protective of misuse or OUD development
– Additional risk?
– Chemical coping
– ↑ prevalence of depression & anxiety – during and after treatment
– Link with SUD
– Regular abuse of some substances ↑ cancer risk
Paice JA. Cancer 2018;124:2491-7.Lee JS, et al. J Clin Oncol 2017;35:4042-9.
Patients with Cancer Represent an Ignored Need
Loren AW. NEJM 2018;379:2485-7.Kata V, et al. Curr Opin Support Palliat Care 2018;124-30.
Huang R, et al. J Clin Oncol 2019;37:1742-52.Sutradhar R, et al. Cancer 2017;123:4286-93.
Peppin J. J Pain Res 2016;9:23-4.
Cancer
Related
Pain
– 70% experience pain during disease
course
– 33% develop long-term pain
– Increased survival
– Risk factors for chronic pain
– Opioids historic cornerstone
– Best for acute cancer pain
– NOT foundation for managing chronic (late) cancer
pain or neuropathic pain
– Adverse effects with long-term use
– Most experience with non-opioid modalities
based on non-malignant dataVan den Beuken-van Everdingen MH et al. J Pain Symptom Manage. 2016;51:1070-1090.Green CR et al. Cancer. 2011;117:1994-2003.
Chronic
Pain
Syndromes
Associated
with
Cancer
Treatment
Chemotherapy• Bony complications
• Avascular necrosis
• Compression fractures
• CTS
• CIPN
• Raynaud’s
Hormonal Therapy• Arthralgias
• Dyspareunia
• Gynecomastia
• Myalgias
• Compression fractures
(osteoporosis related)
Radiation• Chest wall syndrome
• Cystitis
• Enteritis
• Proctitis
• Fistula formation
• Lymphedema
• Myelopathy
• Osteoporosis
• Osteoradionecrosis
• Peripheral
mononeuropathies
• Plexopathies
Immunotherapy• Inflammatory arthritis
• Myositis
• Peripheral neuropathy
• Polymyalgia-like
syndrome
HSCT/GVHD• Arthralgias/myalgias
• Dyspareunia, vaginal pain
• Dysuria
• Eye pain, Oral pain
• Paresthesias
• Scleroderma-like skin
changes
Surgery• Lymphedema
• Phantom pain
• Postmastectomy pain
• Post radical neck
dissection
• Post-surgery pelvic
floor pain
• Post-thoracotomy pain
• Frozen shoulder
• Extremity pain
Adapted from Table 1: Oncology (Williston Park). 32(8):386-90, 403.
New Challenges: Adverse Effects of
Long-Term Opioid Use• Constipation
• Mental clouding
• Pyrosis, bloating, nausea
Persistent, Common AE
• Fatigue
• Infertility
• Osteopenia/-porosis
• Decreased libido
• Reduced/absent menses
Endocrinopathies
• Dysimmune effects: enhanced sensitivity to viral/bacterial insults
• Tumor proliferation
Immune effects
• Myoclonus
• Mental status changes (clouding, mood effects, memory problems, balance)
• Opioid Induced Hyperalgesia
Neurotoxicity
• New & worsening Obstructive Sleep Apnea
Sleep-disordered breathing
• Withdrawal
Physiological dependence, tolerance
• Misuse
• Abuse
• OUD
• Depression
Psychological
1)Eur J Pain 2010; 14:1014-20; 2)Anesthesiology 2012;116:940-5; 2)J Clin Endocrinol Metab 2000; 85: 2215-22.; 3)Pain Physician 14:145-61, 2011; 4)Curr Pharm Des: 18:6034-42, 2012
What Risks are We Trying to Mitigate?
– Opioid-related death
– Often unintentional
– Patient, family, friends, society
– Opioid Use Disorder
– Impact on treatment
– Delays, harm, suffering
– Impact to access for patients who need opioids
Safe Opioid Use Considerations in
Patients with Cancer/Chronic Disease
– Tolerance
– Challenges of acute pain management in opioid tolerant
– Opioid induced hyperalgesia
– Drug interactions
– Opioid dose conversions
– Fentanyl patches
– Survivorship and tapering
– Financial/psychosocial distress
– Disease treatment in relapsed OUD
– Pain management in patients on MOUD
Universal
Precautions
for Opioid
Prescribing
– National/General
– Centers for Disease Control and Prevention
– Federation of State Medical Boards
– Oncology
– National Comprehensive Cancer Network
– American Society of Clinical Oncology
– Palliative/Hospice
– Center to Advance Palliative Care
– American Academy of Hospice and
Palliative Medicine
Adapted from Tables 5 & 6: Journal of Clinical Oncology 2016 34:27, 3325-3345.
• Exam and review of medical records
• Review PDMP
• Conduct initial UDS
Assess pain & risk of misuse
• Stratify risk of diversion and abuseDecide if opioids
appropriate• Optimize non-opioids and non-pharm analgesic modalities
• Multimodal pain approach
• Obtain treatment for psychiatric illness (includes anxiety, depression, sleep disorders, PTSD, etc.)
Minimize risk
• Evaluate effectiveness (5 A’s)
• Review and treat AE
• Monitor adherenceMonitor
• Assess for indicators of uncontrolled pain, misuse, abuse, or diversion
• Intervene – prescribe small amounts at shorter intervals, pill counts, more frequent UDS
• Consult psych/addiction specialists
Respond to aberrant behaviors
Universal Precautions – Opioid Rx
Importance of Expectation
Setting
Healthcare
Expectations
Predicted Ideal
Normative Unformed
Bialosky JE, et al. Phys Ther. 2010;90(9):1345-55.
Setting Pain
Goals
Keltner JR, et al. J Neurosci 2006;26(16):4437-43.Apfelbaum JL, et al. Anesth Analg 2003;97:534-40.
Function
Barriers
Tools
SMART Goal Setting
Monitoring and Addiction
Support
– Set expectations on best practices for monitoring/responsibility
– Standard of care
– Enhances care transitions
– Treat and coordinate care if issues arise (addiction medicine, shift
in treatment plan with safety and QOL in mind)
– Recognize that some patients have severe, complex pain & OUD.
Treatment of both improves outcomes for both disease states.
Impact of
Substance
Use or
OUD
Toward
End of Life
– Health care service access
– Additional health problems
– May have complex social situations
– Fear of being judged or stigmatized
– Difficult symptom management
– Organ dysfunction
– Drug interactions
– Tolerance
– Hyperalgesia
– Greater risk of adverse effects
“Caring for someone with substance use problems at end of life” Marie Curie Website. Available at: https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/equality-diversity/people-with-substance-use. Accessed 9/15/2020.
Stigma
and Bias
– Stigma = label + stereotype
– Bias
– Explicit = conscious
– Implicit = subconscious
– Implicit bias in healthcare professionals
– Significant relationship between implicit bias and quality of
care
– Word selection matters
– Negative explicit bias: “clean”, “dirty”, “medication-assisted
treatment”, “medication-assisted treatment”, “untreated”,
and “alcoholic”, “substance abuser”, “opioid addict”
– More positive explicit bias: “person with a substance use
disorder” and “person with an opioid use disorder”,
“recurrence of use”, “pharmacotherapy”, “medication-
assisted recovery”, “long-term recovery”Ashford RD, et al. Drug Alcohol Depend. 2018;189:131-138.
Kelly JF, et al. Int J Drug Policy. 2010;21(3):202-207.
FitzGerald C, Hurst S. BMC Med Ethics. 2017;18(1):19.
Bias and Levels of Compassion
Disengagement
• Disconnected
• Negative reactions for patient and provider
• Under-prescribing of opioids
Reactive compassion
• Knee jerk compassion
• Perceived as positive by patient and provider
• Over-prescribing of opioids
Conscious compassion
• Mindful compassion
• Perceived as positive by patient and provider
• “Goldilocks” prescribing –prescribing opioids is just right
Putting It Into Practice
Case Discussion
Baptist Palliative Clinic Algorithm
Establishing Care
Intake
• ORT-OUD/ COMM
• UDS
• Review PDMP
• Review medical records
Set Expectations
• Treatment agreement
• Informed consent
• Functional goals
Education
• Safe opioid disposal
• Naloxone
• Opioid safety
ORT= Opioid Risk Tool, COMM = Current Opioid Misuse Measure, UDS/UDT= Urine Drug Screen or Test, PDMP = Prescription Drug Monitoring Program
General Follow Up – All
Patients
Follow up within 1 month if prescribed a controlled medication
Medication counts and PDMP on every visit
For chronic opioid use, review COMM annually
Follow algorithm for frequency of visits and UDT based on ORT/COMM
Follow Up – Patients with History of
Substance Use Disorder(s)
– All general follow up PLUS
– Addiction clinic referral (if not already established)
– Follow-up visit schedule (initial – progression dependent upon aberrant behaviors and UDT results)
– Weekly x 4 weeks then
– Every other week x 2 then
– Monthly thereafter
Case
– 59yo with new inpatient diagnosis of metastatic pancreatic cancer to liver.
– Chronic low back pain on chronic oxycodone 10mg q6h and Gabapentin 800mg 4xdaily
– Started on Fentanyl 75mcg patch with oxycodone 10-20mg q6h PRN
– First outpatient f/u – pt taking all doses oxycodone, reporting use 2 tabs every 4 hours
– 1/2ppd tobacco smoking, 12 beers daily prior to hospitalization, social cannabis currently, remote
(>20yrs ago) occasional cocaine use. Adult child in long-term recovery for polysubstance use
– 1 week f/u: Increased Fentanyl patch, added quetiapine and duloxetine, referred to Behavioral
Health and Interventional Pain
– 1 week f/u: Overuse oxycodone, counseled re: anticipatory pain and anxiety, increased quetiapine,
wife agreed to manage medications
– 1 week f/u: No overuse, pt and wife saw Behavioral Health
– 2 week f/u x2: No overuse. Requested Chantix, down to 1 beer in 2 weeks.
Palliative Care and
Opioid Stewardship
Symptom indication, goals, prognosis, and setting Clarify
Implicit biasRecognize
Universal precautions with opioid prescribingApply
Structure, treatment, & set boundaries when misuse occursSupport
Questions ?