INTRODUCTION
Pain is a common symptom experienced by patients in hospice care and is not limited to those with cancer. While pain in the hospice setting may result from a tumor, it may also be caused by nerve injury, swelling, skin breakdown, worsening disease, deconditioning, or related to a previous injury (chronic pain). Regardless of the reason, untreated or undertreated pain can result in physical distress, increased irritability, decreased function, depressed mood, and ultimately negatively impact relationships.
Pain is also one of the most feared symptoms of the patient near the end of life. Despite this fear and the negative consequences of untreated pain, many patients still have pain that is not adequately managed. Several types of pain medications exist which may provide benefit to the patient. In the hospice setting, the medication used is prescribed by the hospice physician, taking into account patient-specific information when making these decisions.
ABOUT OPIOID THERAPY
Opioids are a class of medications, often used in hospice for pain or breathing. The most commonly used opioids are hydrocodone, oxycodone, hydromorphone, morphine, fentanyl, and methadone. These medications come in a variety of forms, allowing them to be given even when patients have difficulty or are unable to swallow. Opioids are often rapid-acting and have been found to be an essential tool for symptom management in patients with severe, life-limiting illnesses. In the hospice setting, symptoms can be more severe, time may be limited, and a decline in kidney or liver function may limit other pain medication options. Opioid dosing can be customized to the patient-specific scenario for safe and effective symptom management.
ADVANTAGES OF OPIOID THERAPY
Rapidly effective
Unlike some pain medications that may take weeks to provide full benefit, most opioids begin providing pain-relieving benefits with the first dose
Multiple dosage forms
Long-acting or immediate-release tablet
Liquid: for patients with symptoms & difficulty swallowing
Topical patch: long-acting benefit, worn on skin
STARTING OPIOIDS
When adding or increasing an opioid, the hospice team will:
Determine the appropriate starting dose based on patient-specific info
Create a plan for assessing and monitoring opioid therapy
Monitor patient response and adjust the dose as necessary
You can be an advocate by:
Asking questions
Documenting use (request the med dosing log from your agency)
Reporting any questions, issues, or concerns to the hospice team
ADDRESSING COMMON MYTHS OF OPIOID THERAPY IN HOSPICE
Patients and caregivers have both expressed concern about starting opioids in the hospice setting, which is understood if there is little previous experience with opioids. The following will help shed light on the truths of opioid therapy:
Myth:
Morphine is a strong opioid only reserved for use at the very end of life
Truth:
Morphine is considered the gold standard for pain and breathing symptoms.
Doses can be customized to be safe AND effective
Myth:
Once opioid therapy is started, the patient will have difficulty remaining alert
Truth:
Drowsiness can be a common side effect of opioid use
Patients often develop a tolerance to this after a few doses
Symptom relief can increase that patient’s ability to get rest, often improving alertness, comfort, and quality of life
Myth:
Opioid therapy will result in more rapid patient death
Truth:
The goal of opioid therapy is to reduce symptom burden and increase quality of life, not quickening death
At the very end of life, patients may require doses of opioids that keep them sedated in order to be comfortable
Establish goals of care early with your hospice team
CONCERNS OF OPIOID ADDICTION
Headlines highlight the negative impact of opioids. It is understandable how a patient or family may be hesitant to begin opioids. However, in the hospice setting, the team works to create a patient-specific plan to reduce these risks and to ensure safe and effective dosing for reduced symptom burden.