1.
Palliative Care Summer Institute
Basic and Advanced
Pain Management for Clinicians
Margaret A. Jacobson, MD
Shaun Sullivan, MD
Medical Directors, Whatcom Hospice

2.
Palliative Care Summer Institute
Effective pain management is a moral imperative, a
professional responsibility, and the duty of people in
the healing professions
Relieving Pain in America: Institute
of Medicine (2011)

3.
Palliative Care Summer Institute
2010 Washington State Rules regarding chronic pain
management DO NOT APPLY to
 Chronic cancer pain
 Acute pain caused by an injury or a surgical procedure
 Palliative, hospice, and other end-of-life care
Pain Management for whom?

4.
Palliative Care Summer Institute
1986 WHO Pain Ladder

5.
Palliative Care Summer Institute
2015 WHO Pain Ladder

6.
Palliative Care Summer Institute
 Ongoing
 Individualized
 Documented
“Tell me about your pain….”
Pain Assessment: The cornerstone of
optimal pain management

7.
Palliative Care Summer Institute
OPQRST
“Tell me about your pain”
 Onset
 Provoking, Palliating
 Quality
 Region/ Radiation
 Severity
 Treatment
 Understanding

8.
Palliative Care Summer Institute
Universal Pain Intensity Assessment
Tool

9.
Palliative Care Summer Institute
Analgesics should be given “by mouth, by the
clock, by the ladder, and for the individual”
(World Health Organization)
Principles of Analgesia

10.
Palliative Care Summer Institute
 It is not necessary to traverse each step of the ladder
sequentially
 For mild pain (1-3) start at step 1
 For moderate pain (4-6) start at step 2
 For severe pain (7-10) start at step 3
…By the WHO ladder

11.
Palliative Care Summer Institute
 Safe
 Reliable
 Effective for all types of pain
 Have multiple routes of administration
 Are easily titrated
Opioids: Mainstay of treatment of moderate-
severe pain in advanced illness

12.
Palliative Care Summer Institute
 Opioids follow first-order kinetics and pharmacologically
behave similarly
 Peak plasma concentration (C max)
 60-90 minutes after oral administration
 5-10 minutes after IV administration
 Opioids are eliminated from the body in a direct and predictable way,
irrespective of the dose
 The liver conjugates them
 The kidney excretes 90-95% of the metabolites
 Their metabolic pathways do not become saturated
 Each opioid metabolite has a half life that depends on its rate of renal
clearance
 When renal clearance is normal, codeine, hydrocodone, hydromorphone,
morphine, and their metabolites all have effective half lives of
approximately 3-4 hours
 When dosed repeatedly, their plasma concentrations approach a steady
state after about 4-5 half lives (1 day)
Opioid Pharmacology

13.
Palliative Care Summer Institute
 Routine dosing: Dosing interval is 1 half life
4 hours
 Bolus/breakthrough dosing: dosing interval is time to
peak effect
1 hour orally, 10 minutes IV
 Steady state: achieved after 4-5 half lives
1 day
Opioid pharmacology simplified

14.
Palliative Care Summer Institute
 Constant pain needs constant control
 Start an opioid naïve patient with a short acting opioid, and dose
every 4 hours, NOT prn
 The best possible pain control for the dose will be achieved
within a day (once steady-state is reached)
 Provide the patient access to prn doses of the SAME medication
that can be used should breakthrough pain occur
 Every hour for oral opioids
 Every 10 minutes for IV opioids
 Do not use extended release opioids for rescue dosing
 Longer intervals between breakthrough dosing only prolong a
patients pain unnecessarily
Opioid basics

15.
Palliative Care Summer Institute
 Renal considerations
 Opioids and their metabolites are primarily excreted renally
 Morphine has 2 principal metabolites: 3 and 6 glucuronide
 Morphine 6 glucuronide is active and has a longer half life
than the parent drug
 With impaired renal clearance, excessive accumulation of the
drug must be avoided by either
 Increasing the dosing interval
 Decreasing the dose
 With oliguria or anuria, stop routine dosing and administer
only as needed
Renal Failure considerations

16.
Palliative Care Summer Institute
 Opioid metabolism is not as sensitive to hepatic
compromise
 With severe hepatic impairment
 Increase the dosing interval
 Decrease the dose
Liver failure considerations

17.
Palliative Care Summer Institute
DRUG IV PO
Morphine 10mg 30mg
Codeine 200 mg
Hydrocodone 30 mg
Oxycodone 20 mg
Hydromorphone 1.5 mg 7.5 mg
Fentanyl 0.1 mg
Equianalgesic conversions
Important insights:
1. Oral morphine and oral hydrocodone are equally potent
2. Oral oxycodone is more potent than oral morphine
3. Hydromorphone is 4-7 X more potent than morphine

18.
Palliative Care Summer Institute
Opioid side effects

19.
Palliative Care Summer Institute
 Clinician barriers
Barriers to effective use of opioids

20.
Palliative Care Summer Institute
 Patient barriers
Barriers to effective use of opioid