6/9/09 11:57 AM

Creativity for Pain Relief Needed in Palliative Care

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PAIN MEDICINE
ISSUE: 12/2008 | VOLUME: 34:12

Creativity for Pain Relief Needed in Palliative Care

Larry Beresford

The variety of treatments and techniques for treating moderate to severe pain in difficult or complex cases in hospice and palliative care settings is growing. Although oral morphine remains the drug of choice for palliative care physicians, several cases discussed at the California Hospice and Palliative Care Associations 2008 annual meeting indicate a trend toward using anticonvulsants, antidepressants, corticosteroids and anesthetic drugs as primary or adjuvant analgesics. Examples included gabapentin, pregabalin [Lyrica, Pfizer], carbamazepine, tricyclics like amitriptyline and nortriptyline, duloxetine [Cymbalta, Lilly] and venlafaxine [Effexor, Wyeth], dexamethasone, lidocaine, oral and intravenous ketamine and even topical capsaicin. Most clinicians are more familiar with the side effects of opioids than with those of other analgesics, one field leader noted. Some of these other drugs offer more advanced means of treating pain, a more nuanced approach, especially for patients who have experienced opioid neurotoxicity, said James McGregor, MD, pain management physician for Sutter VNA & Hospice, in Sacramento, and a presenter at the meeting. But there are a number of indications and potential side effects we need to keep in mind. Hospice and palliative care physicians from the podium and the audience shared their comfort with prescribing methadone, a popular synthetic opiate that is a subject of much controversyranging from coverage in The New York Times (Methadone Rises as a Painkiller With Big Risks, Aug. 17, 2008) to efforts from the group HARMD (Helping America Reduce Methadone Deaths) to raise awareness of its risks to the FDAs black box warning added to methadones prescribing information on its risk for respiratory depression in February 2006. Presenters and meeting attendees described using methadone for treating neuropathic pain, which often does not respond well to other opioids and can be the most difficult type of pain to manage. The speakers noted that neuropathic pain is seen in 40% of patients with advanced cancer, the most common diagnosis in hospice and palliative care. We are more comfortable with methadone, said Andrew Lasher, MD, a palliative care physician at California Pacific Medical Center and regional medical director for Sutter VNA & Hospice in San Francisco. It is a great drug in the right hands and we feel we are the right hands. We think it is underused as an analgesic and that if you choose the patients wisely and titrate carefully, you are unlikely to run into problems with it. (A recent consensus guideline published in Palliative & Supportive Care [2008;6:165-176] suggested that I.V. methadone is underused in palliative care settings, and the authors wrote that there was insufficient data for its use in managing neuropathic pain.) Pain management clinicians can use more than morphine to help patients, another physician pointed out. Pain control in palliative medicine is much more than morphine, noted Brad Stuart, MD, another medical director for Sutter VNA & Hospice in Sacramento, Calif. Morphine is still the most effective and least toxic analgesic when used appropriately, although it is only partially effective against neuropathic pain, Dr. Stuart said. However, physicians must titrate morphine steadily upward for moderate to severe paineither until the pain is under control or signs of neurotoxicity, such as drowsiness or confusion, or tolerance start to appear, he said. If you are putting the patient to sleep, but the pain is still not relieved, that is a good sign to suspect neuropathic pain. At that point, my usual practice is to add methadone to the treatment cocktail. Dr. Stuart typically starts with a dose as low as 5 mg three times per day, for one or two days before increasing the dose, because of methadones long and unpredictable half-life. Dr. Stuart added that most of the nonopioid analgesics used have their own set of side effects to manage, and most of these drugs are considered for pain that is neuropathic in origin. Other challenging pain syndromes commonly seen in hospice and palliative care settings include pain from pancreatic cancer, bone metastases, bowel obstruction, postherpetic neuralgia and brachial plexus injuries. Whatever It Takes Illustrating the whatever it takes approach to relieving pain and other symptoms in patients with advanced illnesses, Dr. McGregor described an off-label case in which a patient with intractable pain was given palliative sedation with midazolam and phenobarbital for a couple of days of deep sleep before he was slowly reawakened. It is like we reset something in the pain receptors and the pain was not as severe afterward, he said. Palliative sedation would only be considered in the rare cases that do not respond to pain therapy in any other way. At times, the palliative care physician may opt for an antidepressant as adjuvant therapya double benefit if the patient also suffers

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6/9/09 11:57 AM

Creativity for Pain Relief Needed in Palliative Care

from depression. Simplifying the medication regimen for patients with advanced illnesses is one goal for the palliative care clinician. Cost may also be an issue: For patients enrolled in the Medicare hospice benefit, the hospice receives a daily rate intended to cover all services needed to manage the patients care, including pharmaceuticals. Some anesthesia drugs may comprise most of the daily rate, whereas if effective, morphine and methadone cost far less. These issues can get tricky, said Dr. Lasher. We want to give our patients all of these modalities, he said. But at the same time, some of the pressures from the other direction include cost and the need for closely monitoring the administration of some of these drugs, especially in hospice, which primarily operates in the patients home. Hospice and palliative care physicians also closely monitor the interrelationship between physical, psychosocial and spiritual dimensions of pain. Dr. McGregor described a case in which a woman who had been repeatedly hospitalized for pain relief was not responding to multiple analgesics. She had two children who were minors and had not arranged for their custody. As a pain consultant, your first therapeutic intervention is your presence, your listening, your compassion, Dr. McGregor said. The patient had not been willing to confront the reality of her terminal illness, given her fears about what would happen to her children. She wanted to be there for her kids, he said. I decided it did not matter what I did with the drugs until these other issues were addressed. The woman was encouraged to videotape messages as a legacy for her children and to clarify custody arrangements, and then her pain started to abate. The number of palliative care consultants working in acute care settings is growing rapidly, Dr. Stuart said. Anesthesiologists may want to turn to them with cases of refractory pain with obvious psychosocial overlays. At the same time, hospice and palliative care physicians, particularly those working in integrated systems such as Sutter Health, are increasingly turning to anesthesiologists for consultations on their most challenging pain cases for consideration of procedures such as nerve blocks, epidurals, or celiac plexus blocks. Anesthesiologists represent a small but not insignificant proportion of hospice and palliative physicians. Nineteen of approximately 3,000 physician members of the American Academy of Hospice and Palliative Medicine are self-identified anesthesiologists, and among the 2,626 physicians board-certified in hospice and palliative medicine, 57 are board-certified anesthesiologists. The American Board of Anesthesiology is now working with the to certify physicians in the medical sub-specialty of hospice and palliative medicine. Dr. McGregor recommended cultivating a long-term working relationship with an anesthesiologist who has an affinity for palliative medicine. I would also encourage anesthesiologists to become more involved with their local hospice. It could be an invaluable service, in some cases. But I would remind them that in hospice, we are not about death. We are about living and how we can help patients live until they do die. Pain management is an essential part of that. You cannot do important life work if you are doubled over in pain.

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