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8th MALAYSIAN HOSPICE CONGRESS

JUNE 13TH -15TH 2008


BARRIERS IN USE OF OPIOIDS

CLINICAL CHALLENGES IN •Physician


USE OF OPIOIDS
•Patient & Family

Dr Oo Loo Chan •System


Charis Hospice

PHYSICIAN-RELATED BARRIERS Journal Of Pain & Palliative Care Pharmacotherapy


2006; Vol. 20 (2) pp 15-22
• Lack of knowledge Survey among the total population of government hospital
- use of pain medications, pain doctors of Sarawak to study the barriers to cancer pain
management. Two hundred and fifty-three respondents (83%)
assessment, pain mechanism completed the survey. The study results highlight that
• Fear of producing addiction knowledge about cancer pain management was low and
barriers to morphine prescription were high. A majority of
• Concern of tolerance doctors were deterred from using morphine because of fear of
addiction (36.5%) and respiratory depression (53.1%). Only
• Concern of side-effects 16.2% of the doctors chose the oral mode of administration to
• Fear of regulatory scrutiny treat pain, furthermore 25% prescribed morphine on "PRN"
basis.

Common Mistakes:
PATIENT-RELATED BARRIERS
• Too long dosing interval of quick acting
morphine or prn basis • Opioid-induced side effects
• No quick acting morphine given for patients • Erroneous beliefs & Misconceptions eg:
on slow-release morphine -pain is inevitable in terminal illness
• Use of fentanyl patch in opioid-naïve patient -pain is not treatable
without prior titration of opioid dose required -reluctance to report pain
-concern of addiction
-concern of tolerance

1
Case Case
• 46 yr old female with metastatic Ca colon. • Family refused to allow patient to use
Developed subacute intestinal obstruction. morphine for pain relief despite repeated
Pain well-controlled with low dose explanations in private and in front of
morphine, initially orally, then in patient. Apparently the father died in
combination with dexa and buscopan via hospital after a morphine injection and
CSSI. they blamed the doctor. They went to the
Needed repeated reassurances of extent of substituting aq morphine with
usefulness of morphine to overcome water in the medicine bottle. The patient
reluctance of use. finally said in front of his family he rather
die in pain.

CHALLENGE 1:
Common Adverse Effects:
1.GIT: vomiting, constipation
occasional dry mouth
2.CNS: drowsiness, unsteadiness, SEDATION
confusion,hallucinations(auditory or
visual),occasional myoclonic jerks

Case Case
• 53 yr old female with Ca Pancreas. • 54 yr old female with Ca Liver due to
Diabetic with nephropathy. Hepatitis C.
Epigastric pain relieved with Tramadol Discharged from hospital with Tramal
100mg bd for epigastric pain. Very drowsy.
50mg tds.
Clinically no jaundice. ECOG 4.
Drowsiness unacceptable to husband, Husband not accepting poor prognosis.
causing dysharmony in family. Root Tramal stopped and drowsiness improved
issue- probably husband not accepting but still ECOG 4.
prognosis. Which analgesic is suitable?
Combination of analgesics used.

2
Case Case

• 46 yr old female with metastatic Ca ovary • 77 yr old female with Ca colon & CVA.
and PR bleeding from adjacent spread. Arthritis of fingers and backache.
Lower abdominal pain improved with Relocated from outstation. Recently put on
Tramadol 50mg tds. aq morphine 5 mg 4 hrly. Complained of
Frequency of stools. giddiness and refused to get out of bed.
Morphine stopped and advised to be
Preferred to be more awake, thus reducing regular with Mobic 7.5mg od. Giddiness
opioid dose. improved but still has to be coaxed out of
bed!

Case
CHALLENGE 2:
• 66 yr old man with metastatic Ca colon.
Vomited after being started on Duragesic
VOMITING patch 25mcg by hospital. Alternative
analgesic (celecoxib) used but over time,
insufficient pain control. Challenged with
aq morphine 5mg but vomited again after
2 doses. Earlier apprehension about using
opioids aggravated instead of relieved!

Case CHALLENGE 3:
• 68yr old female with metastatic Ca Breast. CONFUSION
Backpain and bone pain R thigh not
adequately controlled with Tramadol &
100mg qid and Celecoxib 200mg bd.
Given Aq morphine 10 mg as HALLUCINATION
breakthrough dose but unable to tolerate
due to vomiting. Finally opioid changed to
Duragesic patch 25mcg with reasonable
pain control.

3
Case
CHALLENGE 4:
• 78 yr old man with Ca Stomach & liver
secondaries. Poor response to chemo.
Started on aq morphine 2.5mg 6 hrly. RESPIRATORY DEPRESSION
Became confused & had visual
hallucinations – these subsided after
stopping morphine. Remained pain-free
for several months. Subsequent RHC pain
controlled on DF118 30mg tds.

Case
• 43 yr old man with recurrent astrocytoma. ECOG CHALLENGE 5:
4 with lucid intervals on and off. Blind. Restless.
On dexamethasone for increased intracranial
pressure. Having headache – started on
Tramadol 50mg tds with instruction to wife to
CONSTIPATION
increase to 100mg tds if headache not
controlled.
Noted more drowsy and not restless anymore
one morning. Cheyne-Stokes resp. PU only
once past 2 days. Stopped all oral medications.
No more Cheyne-Stokes resp but sensorium
remained about the same.

Case
USE OF OPIOIDS
• 54 yr old man with Ca rectum and liver IN CO-MORBID CONDITIONS
secondaries. Colostomy. Tense ascites.
On Aq morphine 5 mg 4 hrly. Constipation •Co-morbid conditions are common in
difficult to control with oral laxatives and palliative care setting
has increased abdominal discomfort if •Co-morbidity (CNS, Metabolic, Infection,
BNO for a few days. Needed bisacodyl Mechanical, Iatrogenic) may mimic opioid-
supp prn via colostomy site. induced side-effects

4
Complained of some low back pain
Mdm SGK & low abdominal pain, preventing her
79 year old from sitting up for long. Family had
Diagnosis: Hepatocellular Ca bought her a wheelchair and taken her
Hepatitis C Cirrhosis once to shopping mall. Her hobby is
Diabetes Mellitus shopping.
Hypertension Switched her to an equianalgesic dose of aq
Main Carer is husband aided by maid morphine 10 mg 4 hrly from tramadol 100 mg tds,
with good support from children aiming for better pain control and planning to
later use long-acting morphine.

WHAT HAPPENED?

• Next morning, family called that she was not ADMINISTRATION OF OPIOIDS
able to talk and drink/eat. Febrile. Clinically VIA DIFFERENT ROUTES
treated as hypoclycemia (even though
glucometer by family – 3.7mmol). Probably
precipitated by morphine induced drowsiness •Oral route, though route of choice,
causing reduced oral intake. Also, possibly may not be suitable in some circumstances
underlying infection even though no fever •Alternative : transdermal, subcutaneous,
detected previous day. intraveous, rectal
Arranged for hospitalization.

Case
LEARNING POINTS:
1. ADVERSE EFFECTS DO LIMIT USE OF OPIOIDS. LOOK OUT
FOR THEM
• 62 yr old female, recurrent Ca Breast with
2. ADVERSE EFFECTS MAY BE AGGRAVATED BY OTHER CO-
cervical lymph node metastasis, MORBID CONDITIONS IN ILL PATIENTS
developed dysphagia esp to clear fluids.
3. REVIEW NEED & DOSE OF OPIOIDS REGULARLY.
Progressively more pain at cervical area ‘ONCE ON OPIOIDS, ALWAYS ON OPIOIDS’ IS NOT TRUE
and needed more aq morphine. Pain 4. BE FAMILIAR WITH DIFFERENT OPIOIDS, EQUIANALGESIC
subsequently reasonably controlled with DOSES & ROUTES OF OPIOID ADMINISTRATION

fentanyl patches 75 mcg/hr with 2-3 doses 5. CONSIDER AVAILABILITY OF OPIOID, CONVENIENCE, COST,
PREFERENCE OF PATIENT AND FAMILY
of aq morphine 20mg daily for
breakthrough pain. 6. PREPARE PATIENT & FAMILY FOR POSSIBLE EVENTUAL USE
OF OPIOIDS

5
OUR GOAL IS TO MAINTAIN
OPTIMAL BALANCE BETWEEN
ANALGESIA AND SIDE-EFFECTS

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