REAL Pain or ADDICTION?

[captain morgan]

To all of you hospice pain gurus: I have a pt that has been taking Lortab 6xday with MS Contin (100mg) bid and Roxanol (20mg:1ml) 1ml q1-3 hrs prn breakthrough pain, and Fiorcet prn for headache (he takes at least 3 per day). Every time I ask him what his pain is - it's always at least a 7 and usually 10+ (Dx: lung CA). Meanwhile, he is conversing with me and his spouse without any apparent distress, joking around and such. Spoke with his MD and his meds got changed to Methadone, Decadron and Roxanol for breakthrough. He lasted 2 days and requested to be switched back to the Lortab regimen. He had a change of mental status (per spouse), and broke out in blotches - although he did not complain of a rash or itch. I'm just astonished that the methadone did not work - I've heard such good things about it. It makes me wonder whether this pt just loves his Lortab??? What do you think???

[leslie :-D]

In general, I agree that having multiple kinds of opiods usually doesn't make sense -- it's often more confusing to the pt and just not necessary. BUT there are things to consider: poor kidney function? Best bets are Fentanyl and Methadone (least amount of metabolite accumulation) see Fast Fact 161. Liver failure? Again, Fentanyl seems to be the safest product (issues of clearance and first pass effect). A really good article on medications in liver failure is

Palliation and Liver Failure: Palliative Medications Dosage Guidelines (2007)

Rhee, C., & Braodbent, A.M.. Journal of Palliative Medicine, 10(3), 677-685.

I'm curious as to why you hate fentanyl. I've had good success with it, and when I have a confused patient who is not on an infusion, it makes dosing easier. Also, while I know they say you need SQ fat for absorption, I haven't noticed a major drop in efficacy w/cachextic pts.

I'm also curious why Karen George was so adamant about not using gabapentin -- again, for nerve pain it has done wonders -- pregabalin too when someone has limited time for titration. No experience with any of the side effects mentioned (suicidal ideation, memory loss).

I realize this is an old thread, but I also feel an urge to comment about the whole addition issue. I used to be totally "tx the pain of the person as they say it is." But I've also come to see the need for people with chronic pain to have a more biobehavioral approach. The reality is that pain medication can only do so much. In a non-(imminently) terminal person, the thing to focus on is function -- what will give the person the best possibility of having the highest level of function? What are the other tools that can be used (psychological as well as physical) that will give them the best QoL? To me, it's analagous to just throwing SSRIs at a person with MDD -- usually, pills alone are not going to solve the problems. I'm not saying we judge and not give meds, and not recognize the potential tolerance in someone w/a drug abuse background and punish them, but we (the health care system) are responsible for creating more addicts, and we have to be more responsible with how we prescribe.

Just my

miriam

i just don't think that biobehavorial approach is realistic if the pt isn't interested in obtaining such insight.

clearly, qol is subjective, meaning many things to many people.

i do believe in these approaches for those w/chronic pain.

such regimens are multi-faceted to living w/cp:

including opioids, antidepressants, psych/behavorial and physical therapies.

yet, it is something i wouldn't expect hospice pts to pursue.

if they chose to, wonderful.

if not, that's perfectly ok too.

whatever makes it easier for them to deal.

leslie

[marachne]

Some of my response regarding looking at things beyond pain meds (in chronic pain, NOT for people on hospice) is coming out of my work background -- which is the VA. In the VA, anyone who is going to be on long-term opiods is required to sign a opiod contract. The idea is to direct people to resources that may, or may not help them, but have to at least be attempted. If someone with DJD expects to gain a pain free state from the use of meds alone, it ain't gonna happen.

The idea is to look at what is realistic, and reasonable, and then work w/them to achieve that, as well as to see what are the other factors in their pain profile besides their disease. B/c it is the VA, they can say to them: "if you want to be tx here, you have to play by our rules, and that includes trying to achieve pain control through multiple modalities." The other part of this is that it seems that part of hyperanalgesia is that as you up the pain meds, you actually increase the excitability of the pain pathways -- in other words, it can get to the point that just throwing more opiods at it may make the pain WORSE.

I've heard talks/read papers by several of the experts in pain management, and some of them are saying that maybe we went too far in just giving folks what they want -- that maybe we've created some problems and that a different approach is actually going to be more efficacious.

Personally, I think bringing in more CAM (acupuncture, massage, guided imagery) would help a lot of people with CP.

Oh, and if you're not aware of this site, and you're interested in pain management, you should check it out! It includes specifics for palliative care, cancer pain, etc. etc.

[leslie :-D]

ah, ok.

i thought you were referring to our hospice pts.

since that is not the case, i agree w/you 100%.

and yes, the medical community has indeed, created 'monsters'...

meaning, these folks who live w/cp, often refuse any supplemental txs.

that, only narcotics work.

and it's unrealistic to think that all pain will be absolved.

you're right.

it's not going to happen.

and, these pts ultimately proclaim that "only xxx works".

they don't even see that they're addicted because, well, they have actual pain and need these meds.

yes, i too have seen the paradoxical responses.

i'm glad we're on the same page.:)

leslie