Is Opioid Use the Same in Palliative Care?

LAS VEGAS — Prescribing opioids for patients suffering from pain often depends on several conditions, but what clinicians may not be thinking about is how narcotics come into play when someone is in a palliative care setting.

There are a few universal precautions for clinicians to consider before prescribing opioids to a patient: Apply the systematic approach to all patients when managing pain. This means assessing who is at risk for misuse and abuse, receiving informed consent, and practicing safe prescribing.¹ Clinicians should limit weekly drug supply, document pill counts, schedule weekly follow ups, and conduct a check of prescription drug monitoring program (PDMP) at each visit.^1,2

“The approach to prescribing opioids should be very similar in both pain and palliative care (with a few minor exceptions),” said Dr. Rabia Atayee, PharmD, BCPS, associate clinical professor of Pharmacy at the University of California San Diego Health System and Skaggs School of Pharmacy and Pharmaceutical Sciences.

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Opioid prescribing is often misunderstood, especially when it comes to palliative care, she told attendees. “Palliative care has been shown in literature to be useful at the time of diagnosis of a serious illness, Dr. Atayee said. “Palliative care is no longer thought of as care that is useful just at the end of life.”

Understanding how opioids can be used in palliative care can help clinicians avoid overprescribing narcotics to patients. In both pain and palliative care settings, initiation, titration, adverse effects, and safe prescribing guidelines are the same, Dr. Atayee said.

Opioids can be used for dyspnea in the palliative care setting. In fact, opioids are the drugs of choice for the symptom.^3,4 “In the inpatient setting, patient-controlled anesthesia is the best way to optimize management of both pain and dyspnea,” she said.

“Because some practitioners still think of palliative care as end-of-life care, their misconception is that opioids are used aggressively without much regard to the opioid’s pharmacology or safe prescribing with opioids,” she said. “The pharmacokinetic and pharmacodynamic properties of opioids remain constant, and this should be a consideration regardless of whether opioids are used in palliative care or chronic pain.”

“Safe prescribing is important for all controlled substance medications in any setting,” Dr. Atayee advised.

References

1. Gourlay D, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112. 

2. Smith HS, Passik SD, eds. Pain and Chemical Dependency. New York, NY; Oxford University Press: 2009.

3. Fohr SA. The double effect of pain medication: separating myth from reality. J Palliat Med. 1998;1(4):315-328;

4. Viola R, Kitely C, Lloyd NS, et al. The management of dyspnea in cancer patients: a systematic review. Support Care Cancer. 2008;16:329-33