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Help! MS Contain vs Roxanol reaction

Posted

I'm a new hospice nurse (3 months). I was an LPN for 8 years, now an RN x 1 year. So here's my problem. I have a pt DX COPD, who has been taking Roxanol 1ml at least 6-7 times daily for several months for back pain, generalized pain and he even c/o "organ pain". He's a new pt to me and I'm not sure why it went this far but I understand that 3 months ago the nurse got an order for ms contain 15 mg q 12 and he says he went crazy and was hallucinating the second day. He also admits he didn't stop the roxanol at that time so he was taking both. I spoke with his MD today and he ordered ms contain 45 mg q 12, D/C the Roxanol, and add MS IR 15mg q4 prn. The MD assured me he could not have a true reaction to the ms contain because he is already taking morphine. He said no to having narcan on hand as it would put him in withdrawal. This is to begin day after tomorrow and I will be spending 3-4 hours with him to be sure he does OK. TBH I'm more than a little nervous. Has anyone heard of someone tolerating morphine intensol but not slow release? They are chemically identical. Could he not be getting rid of it? What if he reacts again. He'll be off the roxanol 4 hours prior to first dose.

4boysmama

Specializes in Hospice + Palliative. Has 4 years experience.

does pt have history of drug use? that would increase his tolerance of opiates. Now, as far as a "reaction" - it sounds like he was flooded with meds doing the MS Contin and the roxanol together, thus the hallucinations. so, I don't think doing the MSContin now (if the roxanol is being d/c) is going to cause a reaction. at least, not like that last time. however....if this pt has been getting at least 120mg+ of morphine per day with the roxanol, and he's now switched to standing q 12 ms contin at 45mg (for a total of 90mg) then unless he gets enough doses of the prn MS IR to make up the difference, he'll be undermedicated and will likely have some withdrawl symptoms. it sounds like you are hesitant about him getting too much (thus wanting the narcan on hand) so i'm nervous that you will try to get him to hold off on the PRN, effectively underdosing him.

I don't understand why the switch to contin/IR combo if he's on hospice? at some point, it's likely that he will be unable to swallow pills, in which case you'll have to go right back to the roxanol. why not just continue the roxanol and titrate it to the pt's comfort? as I'm sure you know, morphine alleviates dysnpea, and it is a godsend for end-stage COPDers. I've had more than a few hospice folks on 1mL roxanol q2, and two that I can recall recently that were in the last week of life on 1mL q1. I'd rather have had them on a CADD pump at that point, but family werent' agreeable.

anyway, long story short - why the switch? If he's not getting relief from the current dosing of roxanol, wouldn't it make more sense to titrate up to pt's comfort rather than play with new meds formulations? Or lower the current roxanol dose some and add another pain management, like a fentanyl patch so that you're getting the same overall opiod dosing, but better, even coverage with the long acting patch and short acting roxanol? plus, that will help if the reaso he's having persistent pain is due to hyperalgesia from morphine metabolites building up. does this pt have comorbid liver isues?

Edited by 4boysmama
fixing my math!

Thank you for replying 4boysmama. Yes he has a known history of drug abuse. While he does have copd he's not on dependant, he has some labored breathing and so with exertion. I don't see true dyspnea. I believe he came onto service way too early. He administers his own meds and says he forgets to take it alot. We feel he has become addicted and is abusing the morphine, to be blunt. He doesn't appear to be in that degree of pain. When I've talked about trying longer acting meds he says they are "like spitting in the wind" and they wouldn't be strong enough. I've brought up the fentanyl patch and he says he once had the same hallucinations with it. I appreciate your thoughts on using the prn IR and will certainly recommend it as soon as it looks like he may need it. No liver DX on file.

4boysmama

Specializes in Hospice + Palliative. Has 4 years experience.

I had a feeling that was going to be your answer! I might suggest methadone then, it'll be effective for pain (cause that's whatever the patient says, even if he smiling when he says it lol!) without the nice *high* the roxanol gives. The downside of methadone is that you'll have to monitor him very carefully with daily visits for the first week at least.

How soon till his recert? Can you live discharge due to no decline?

4boysmama

Specializes in Hospice + Palliative. Has 4 years experience.

Honestly, how the heck does non-o2 dependent copd get hospice certified in the first place?!

annabanana2

Has 2 years experience.

Honestly, how the heck does non-o2 dependent copd get hospice certified in the first place?!

It's so interesting to see how you folks in the US do things. Up here in the great white north (in my area at least) there's no such thing as being "declared palliative" or "hospice certified." Home health is who does hospice/palliative care, so most frequently with our chronic disease folks there's really just... kind of a gentle transition from traditional home health services to more end-of-life oriented care. I honestly suspect with our population growing older and living longer with more chronic diseases, this is the direction you folks will end up taking as well. It's not like it used to be back in the day when "palliative" folks were really just the ones with terminal cancer or whatever. Things are much mushier now. It's very difficult often to draw a clear line between "not palliative" and "definitely palliative now." Are you folks finding that too?

4boysmama

Specializes in Hospice + Palliative. Has 4 years experience.

It's so interesting to see how you folks in the US do things. Up here in the great white north (in my area at least) there's no such thing as being "declared palliative" or "hospice certified." Home health is who does hospice/palliative care, so most frequently with our chronic disease folks there's really just... kind of a gentle transition from traditional home health services to more end-of-life oriented care. I honestly suspect with our population growing older and living longer with more chronic diseases, this is the direction you folks will end up taking as well. It's not like it used to be back in the day when "palliative" folks were really just the ones with terminal cancer or whatever. Things are much mushier now. It's very difficult often to draw a clear line between "not palliative" and "definitely palliative now." Are you folks finding that too?

(bolding mine) I doubt much that we'll go that route, because hospice is a 100% covered benefit with rtaher strict criteria to qualify for from medicare (ie: government footing the bill). here, palliative is incorporated into are for any complex medical issues, it's NOT just end of life stuff. anyone can get palliative care. Hospice is specifically end of life, with the requirement that a doc says the prognosis is

Wanted to let you all know the patient transitioned to the ms contin fine with no adverse se. He had some withdrawl sx, diarrhea and restless legs, due to him withholding the roxanol a full day prior to the switch - which Noone asked him to do. These sx resolved throughout the first day on the new med. Thank you for your feedback. I really needed the reassurance at that time.

Pbrown1414

Specializes in Hospice. Has 37 years experience.

Just to clarify, if medicare is covering Hospice 100%, that does not mean "government footing the bill". It means the insurance that the patient paid into all of his working life, is covering the bill. Sorry, this from a near medicare eligible nurse.

Pbrown1414

Specializes in Hospice. Has 37 years experience.

one of the things we can do with a patient like this is to do continuous care for 24 to 48 hours, for "intractable pain". We can control the meds that way and get a true picture of what it takes to manage/control the pts pain. And then, if it is clear that the patient is abusing the meds and doesn't truly fit the hospice picture, he can be discharged for cause, ie "not hospice appropriate".

Just a suggestion as you are still pretty new to hospice.

You wrote about "1 ml of roxanol" - which does not give really give all the information as there are different concentrations available. While our hospice patients are usually on the concentrated 20 mg/ ml liquid Morphine, there are also other concentrations in use and especially for COPD! It is good practice to talk about the "mg" instead of "ml"....