"palliative" non-cancer chronic pain and opioids

[ctts]

This topic has been brought up in a few other threads, but not sure that it has been the focus of any thread.

I have seen some of you use the term "palliative" to describe some non-cancer situations where you may consider low dose opioids <50 MME.

I appreciated Baron Samedi's post which addressed one aspect of this topic:

Dementia is a terminal diagnosis. If she's only 70 and already has moderate dementia as measured by a validated scale, she is palliative.

Characterization of Dementia and Alzheimer’s Disease in an Older Population: Updated Incidence and Life Expectancy With and Without Dementia

Objectives. We estimated dementia incidence rates, life expectancies with and without dementia, and percentage of total life expectancy without dementia.Methods. We studied 3605 members of Group Health (Seattle, WA) aged 65 years or older who did not ...

www.ncbi.nlm.nih.gov

But I think some of you have used palliative to describe situations where perhaps death is not necessarily expected in the next 1-2 years.

As you may know from my earlier post, I am in the process of stopping chronic opioid prescribing. But I have a few patients where I wonder if they some would consider under a broader definition of palliative, and therefore worth considering continuing their opioids. So I am hoping this discussion might help me better form an opinion on how to handle these situations.

For example, I have an 83 year old with severe glenohumeral arthritis, almost zero ROM with that shoulder, and any movement is extremely painful. A sweet little old lady, tries to put on a happy face, but but daughter says she is tearful at times. Significantly affects sleep. Not a candidate for shoulder replacement due to age and comorbidities. I don't think dementia is a significant factor for her. She is not going to die from her shoulder condition, so I normally would not consider her palliative, but she is not going to get better either, and her expected longevity is probably not that much longer at her current age. But then again, longevity is relative, and maybe she could live to 90's, which is at least 7 more years, and a long time to manage opioids. I am imagine that even some of you who would not call her palliative might still consider her for low dose opioids. Anyway, not expecting any concrete answer here, but just wanting to get a sense of how others here view this general situation, and not limited to my particular patient that I presented as an example.

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[Ducttape]

palliative care =/= death in any specific number of years.

from cancer.gov:

Palliative care is care given to improve the quality of life of patients who have a serious or life-threatening disease, such as cancer. Palliative care is an approach to care that addresses the person as a whole, not just their disease.

In my opinion, palliative care is for those patients that there is no long term expectation for self-improvement, either physically, socially, or psychologically.

your 83 year old is not expected to learn to manage her disabilities and pain. she wont be able to aggressively focus on rehabilitative model to improve her functionality. there are no expectations that she will be returning to work or finding some form of gainful employment in the future. she is not a candidate for surgical intervention to repair the condition. while she may be able to work on ACT, the time frame is relatively short for her with respect to this. there are risks to opioids, including tolerance and dependency but the time frame is much shorter than, say, a 50 year old.

so she would be someone that I would think is an appropriate patient for palliative use of low dose opioids, assuming she passes muster with regards to her UDS and her and her and her family psychology.

I will post interesting stories below in next thread regarding why we still need to be diligent.

 

[deleted875186]

This topic has been brought up in a few other threads, but not sure that it has been the focus of any thread.

I have seen some of you use the term "palliative" to describe some non-cancer situations where you may consider low dose opioids <50 MME.

I appreciated Baron Samedi's post which addressed one aspect of this topic:



But I think some of you have used palliative to describe situations where perhaps death is not necessarily expected in the next 1-2 years.

As you may know from my earlier post, I am in the process of stopping chronic opioid prescribing. But I have a few patients where I wonder if they some would consider under a broader definition of palliative, and therefore worth considering continuing their opioids. So I am hoping this discussion might help me better form an opinion on how to handle these situations.

For example, I have an 83 year old with severe glenohumeral arthritis, almost zero ROM with that shoulder, and any movement is extremely painful. A sweet little old lady, tries to put on a happy face, but but daughter says she is tearful at times. Significantly affects sleep. Not a candidate for shoulder replacement due to age and comorbidities. I don't think dementia is a significant factor for her. She is not going to die from her shoulder condition, so I normally would not consider her palliative, but she is not going to get better either, and her expected longevity is probably not that much longer at her current age. But then again, longevity is relative, and maybe she could live to 90's, which is at least 7 more years, and a long time to manage opioids. I am imagine that even some of you who would not call her palliative might still consider her for low dose opioids. Anyway, not expecting any concrete answer here, but just wanting to get a sense of how others here view this general situation, and not limited to my particular patient that I presented as an example.

I would give this lady opioids if she had exhausted injections and non opioids. Outside of tylenol, NSAIDs, topicals, I would probably prefer low dose opioids than many other non opioids in this case to try and limit some of the side effects of these other meds.

 

[Ducttape]

I have had 3 referred elderly patients - to evaluate opioid use - in the last 4 months where it was clear that the elderly patient was not using the opioid medications.

they are always accompanied by a daughter or younger family member that "speak for my mother" and profess to the great benefits of the opioids.

the patients themselves cannot recall actually taking the pills - in all 3 cases, their family member gives them their medications.

in all 3 cases - early refill requests from family member and abnormal UDS ie negative, including spot urgent testing.

 

[drusso]

I have had 3 referred elderly patients - to evaluate opioid use - in the last 4 months where it was clear that the elderly patient was not using the opioid medications.

they are always accompanied by a daughter or younger family member that "speak for my mother" and profess to the great benefits of the opioids.

the patients themselves cannot recall actually taking the pills - in all 3 cases, their family member gives them their medications.

in all 3 cases - early refill requests from family member and abnormal UDS ie negative, including spot urgent testing.

F8ck them. Punish the patient.

 

[Ferrismonk]

I have had 3 referred elderly patients - to evaluate opioid use - in the last 4 months where it was clear that the elderly patient was not using the opioid medications.

they are always accompanied by a daughter or younger family member that "speak for my mother" and profess to the great benefits of the opioids.

the patients themselves cannot recall actually taking the pills - in all 3 cases, their family member gives them their medications.

in all 3 cases - early refill requests from family member and abnormal UDS ie negative, including spot urgent testing.

Great argument for Butrans here.

 

[Ferrismonk]

I don't write much opioids anymore, but here is the template I use in this situation:

Given the (patient’s disease process is a progressive and painful disease without any known cure/patient has a progressive and terminal illness that he/she does not wish to be treated for), I am considering the patient to be a palliative care patient. My primary goal is to keep the patient as comfortable as possible with the understanding that this shift in treatment goal might include increased risk of overdose and death. This was discussed in detail with the patient and he/she agrees.

I would also note that the patient is not a surgical candidate in my note.


I would also mention that you may consider DME as well. A brace may help her pain and increase her function. In this patient population, you aren't as worried about weakening muscles or destabilizing joints.

 

[drusso]

Great argument for Butrans here.

Or even 1/2 2mg SL buprenorphine BID if insurance doesn't pay for the patch.

 

[SeniorWrangler]

I don't know. Maybe someone who's got a severe medical illness and is already on comfort care/DNR status, I could consider palliative.
I'm not sure what calling someone who could easily live another 10-15 years "palliative" gets you.

 

[lobelsteve]

My afternoon looks busy. Too many young folks?

 

[drusso]

View attachment 341640


My afternoon looks busy. Too many young folks?

Why so old? Where's all the MTB'ers, hikers, LAX'ers?

 

[lobelsteve]

Why so old? Where's all the MTB'ers, hikers, LAX'ers?

No hikers. LAXers seen in my home clinic .
A few MTB folks, lots of chronic wrist pain after Fx. A few disc blowouts with bad landings.

 

[buddababa]

View attachment 341640


My afternoon looks busy. Too many young folks?

20 in an afternoon. Impressive. I can barely get my staff to work fast enough to see 10-12

 

[lobelsteve]

20 in an afternoon. Impressive. I can barely get my staff to work fast enough to see 10-12

I was out of office all week. This is 12-4PM. Typical afternoon is 12-15 patients.

 

[Ducttape]

Why so old? Where's all the MTB'ers, hikers, LAX'ers?

do they get chronic pain?

 

[drusso]

do they get chronic pain?

Of course. There is a chronic pain epidemic.

 

[Ducttape]

but... isn't PRP and SCS and periph stim curing the epidemic?

 

[lobelsteve]

do they get chronic pain?

The ones we all see do get chronic pain. Or we would not see them?
Exception: acute radic. Traumatic Fx

 

[drusso]

but... isn't PRP and SCS and periph stim curing the epidemic?

Yes. Little by little, a bird builds its nest...we have generations of patients to treat...

 

[Ducttape]

The ones we all see do get chronic pain. Or we would not see them?
Exception: acute radic. Traumatic Fx

it would be so nice to see a MTB'er or hiker or LAX'er in my office.....

I did see a climber a couple of years ago.

if only the ledge of 2nd story of the bank wasn't so slippery...

 

[deleted875186]

I have had 3 referred elderly patients - to evaluate opioid use - in the last 4 months where it was clear that the elderly patient was not using the opioid medications.

they are always accompanied by a daughter or younger family member that "speak for my mother" and profess to the great benefits of the opioids.

the patients themselves cannot recall actually taking the pills - in all 3 cases, their family member gives them their medications.

in all 3 cases - early refill requests from family member and abnormal UDS ie negative, including spot urgent testing.

This is high risk in my mind. Huge amount of opioids on the street are being sold by elderly to help support their fixed income, big problem, big risk to the prescriber as well. These people need to be more severely punished when caught, instead it’s just the doctor that looses their DEA license.

 

[bedrock]

This topic has been brought up in a few other threads, but not sure that it has been the focus of any thread.

I have seen some of you use the term "palliative" to describe some non-cancer situations where you may consider low dose opioids <50 MME.

I appreciated Baron Samedi's post which addressed one aspect of this topic:



But I think some of you have used palliative to describe situations where perhaps death is not necessarily expected in the next 1-2 years.

As you may know from my earlier post, I am in the process of stopping chronic opioid prescribing. But I have a few patients where I wonder if they some would consider under a broader definition of palliative, and therefore worth considering continuing their opioids. So I am hoping this discussion might help me better form an opinion on how to handle these situations.

For example, I have an 83 year old with severe glenohumeral arthritis, almost zero ROM with that shoulder, and any movement is extremely painful. A sweet little old lady, tries to put on a happy face, but but daughter says she is tearful at times. Significantly affects sleep. Not a candidate for shoulder replacement due to age and comorbidities. I don't think dementia is a significant factor for her. She is not going to die from her shoulder condition, so I normally would not consider her palliative, but she is not going to get better either, and her expected longevity is probably not that much longer at her current age. But then again, longevity is relative, and maybe she could live to 90's, which is at least 7 more years, and a long time to manage opioids. I am imagine that even some of you who would not call her palliative might still consider her for low dose opioids. Anyway, not expecting any concrete answer here, but just wanting to get a sense of how others here view this general situation, and not limited to my particular patient that I presented as an example.

agree with below, that butrans is recommended if you write chronic meds. There are now various discount programs that now reduce the monthly cash price of butrans to $50-60 a month. Everyone even seniors can afford that, depending on other priorities, and that way their kids can’t abuse it.

additionally, this elderly lady sounds like a prime candidate for a shoulder sensory nerve ablation. refer her to someone in your state that does those.