Palliative Care PART – 6
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Last time we covered some important aspects of pain management related to opioid usage. 1. 3rd step in WHO analgesic ladder. 2. Several misconceptions and issues of availability limit use of opioids in India. 3. Misconceptions: fear of addiction. In reality it is extremely rare. Fear of tolerance. In reality this is not an important issue, since there are many levels of dosing with adequate pain relief possible without fear of complete tolerance. Fear of side effects. In reality, one of the safest pain killer. Fear of respiratory depression – avoid by starting at low dose for first few days. Constipation – prevent by prophylactic prescription of laxatives and patient counselling.
Are there any other important points we should know about opioids?
Ans: Yes. Apart from the misconceptions that we discussed last time, one more is the fear of sedation. Many patients feel that once they start morphine, they will remain sleepy and hence unable to perform activities of their choice.In fact, many patients have poor sleep due to pain, with secondary day time sleepiness. When they start morphine and achieve good pain control, they have a good quality restful sleep. So first 1-2 days, they may sleep a lot more, as they are catching up on lost sleep of days to months depending on duration of their pain. After 1-2 days, they will be actually fresh for more hours in the day as they are now getting better pain free sleep. Hence one can say that morphine will actually improve their activity level, as they are fresh now and also have better concentration as they are not distracted by constant pain. Overall quality of life improves remarkably. We have seen this so many times at Karunalay, our cancer palliative care center. Patients who get admitted there, for pain, and receive morphine, some of them sleep a lot for first 1-2 days. Thereafter they feel much better. And even with same or higher doses, they sleep only normal hours and yet are fresh. They are able to eat better, concentrate better, their mood is better (no longer irritable due to constant pain) with better social interactions. In words of family, “we have seen her smile after several months” or “he is back to his normal self now”. We have patients who have resumed their jobs after good pain control, as they are now able to focus on things other than pain.
Another misconception is: when doctor prescribes morphine, it means end is near. As discussed above, patients have actually gone back to their job after starting morphine. Many patients who present with very severe pain due to advance cancer, need morphine initially, but as their cancer is controlled better or removed, they actually come off morphine. And they may never need morphine again. Many patients are on low to moderate dose morphine for several months, in stage 4 cancers. Morphine prescription has no relation to life expectancy, only relation to severity of pain. Also, morphine does not affect life expectancy in any way. Morphine is prescribed in non cancer conditions as well. For example, patients with sickle cell disease pain crisis, frequently require morphine for few days during hospitalization. All of these patients are off morphine after few days. Similarly, morphine is used for control of severe postoperative pain in non cancer surgeries too – very frequently in developed countries. Again, this is only for few days. It is also used for severe pain related to acute myocardial infarction, bone fracture etc. All of these examples also point to the fact that Addiction due to morphine is an extremely rare issue.
Que: Thank you. These are very important points too. What about non morphine opioids?
Ans: Yes. Non morphine opioids are also in use. Less in India compared to developed countries again. Since we have very few choices other than morphine. Best option in this category is probably Fentanyl. Intravenous use is for severe pain of all types, not just cancer. But this is of course limited to hospitals. Fentanyl patch is frequently used for severe cancer pain, even by non oncologists. In fact, many doctors uncomfortable with morphine do treat severe cancer pain with fentanyl patch alone. Probably since they feel lower risk of addiction or self medication with patch. Fentanyl patch of 25 mcg is equivalent to about 50-60 mg of oral morphine. Hence ideally not the best starting medicine for an opioid naïve patient, as discussed in last article. Also, it is important to remember its limitations: 1. Analgesic effect starts about 12 hours after patch is applied. 2. If not applied properly, it does not work well. 3. Titration of dose for pain control is difficult, unlike oral morphine. 4. Fairly costly medicine, not suitable for long term pain control for many patients. 5. Breakthroughpain still possible and this requires oral morphine. 6. Timely change of patch i.e. approximately every 72 hours is required. Due to high cost, I have seen many patients trying to extent use to several days, resulting in poor pain control.February 14th 2020.
Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedahbad. firstname.lastname@example.org