Palliative care – 5 – Pain 3
Palliative Care PART – 5
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Last time we covered some important aspects of pain management in palliative care. 1. Setting the expectations. 2. Sleeping pills/sedatives should not be prescribed for pain control. 3. Neuropathic pain requires different medicines such as pregabalin, gabapentin, duloxetine, amitryptiline. 4. Neuropathic pain in certain sites can be treated well by nerve blocks. Most well known example is cancer of pancreas, where celiac plexus block provides very good pain relief. 5. For any difficult pain, involve oncologist or preferably a pain specialist.
Now going back to the analgesic ladder by WHO, 3rd and final step is Opioids. What should our readers know about opioids?
Ans: When it comes to cancer pain, opioids have a very important role to play. In fact, large majority of patients in stage 3 or 4 cancer will require opioids at some time in their journey of cancer. Opioids are used much more widely in the developed countries for cancer pain. Even primary care doctors there prescribe opioids fairly routinely. Also used widely for postoperative pain. Usage in India however is extremely low compared to the need.
Opioids is the area where maximum misconceptions exist, in the society at large. Biggest probably is the fear of addiction. Many patients are not willing to start due to this fear, and doctors not willing to prescribe. It is extremely rare for a cancer patient to get addicted to opioids.It is generally less than 3% and in many case series it is nearly zero. Hence, under treatment of pain should not be done out of fear of addiction. If standard principles are followed, addiction is nearly zero in cancer patients.
Que: Are there any other factors affecting opioid usage in India?
Ans: Yes. One other factor is the belief that opioids should be reserved till end for severe pain. That if you use it early, there will be tolerance or resistance will develop, and then no pain medicine will be available in end stages. This myth is also the reason for patient not even taking morphine prescribed for him. Or family not giving morphine. Morphine is the most common opioid used.
Additionally there are issues of availability. Due to very stringent laws regarding its storage, distribution, only rare pharmacies are willing to keep these extremely important medicines. For same reason, most hospitals also prefer not to keep morphine.Cost of these medicines is very low, especially of morphine. A lot of NGOs and other experts have been trying to improve the laws governing opioids, so that pharmacies and doctors both are more comfortable to store or prescribe. However, the reforms are still in limited regions and not nationwide. With more experts available to treat pain, usage of opioids has increased in India, but far from optimal levels.
Que:Are there any serious side effects because of which doctors are afraid to prescribe?
Ans:This is probably one of the safest medicines, if basic principles are kept in mind. Unlike NSAIDS, there is no effect on kidney. Nor on liver, or blood counts, blood pressure etc. Some patients may have nausea initially, but it is easy to treat. Constipation is the most common side effect, but again easy to prevent and treat.
What most people fear is Respiratory depression from overdose. It is important to note that this side effect is extremely rare. I can remember only a couple of patients in my 20 years of oncology experience. This generally happens when someone starts at high dose in a patient who is in severe pain. Even if patient is in severe pain, start at a low dose and titrate gradually over a couple of days. Then it is extremely rare. I have seen people prescribing Fentanyl patch 50 mcg as first opioid for the patient who is in severe pain. A 50 mcg fentanyl patch is equivalent to 120 mg morphine. A patient who has not been on any opioids, so called opioid naïve patient, is at higher risk for respiratory depression with high dose. On the other hand, a patient who has been on opioids for even few days, is very unlikely to get respiratory depression even from accidental overdose.
We start patients on 5 mg morphine every 4-6 hours depending on requirement and titrate over few days to achieve good pain control. This is done on outpatient basis by proper instructions to the patient. There is a wide variation in dose requirement. Some need only 10-20 mg per day, while some need even 100 mg or more per day. Fentanyl patch is a good addition, although somewhat expensive, to provide smoother 24 hours relief. Patch releases medicine transdermally in blood continuously for 72 hours. Then a new patch is required. We routinely give laxatives like cremaffin for prevention of constipation with first prescription of morphine. How to optimize morphine and fentanyl dose can be learned easily with short training or interactions with treating oncologist in few cases.
January 12th 2020.
Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedahbad. drchiragashah@gmail.com