Opioid overdoses have reached epidemic levels, requiring urgent action within the healthcare sector. This crisis involves layers of complexity, including chronic pain management, opioid use disorder (OUD), and the unintended consequences of policies aimed at controlling misuse. Expert discussions from the AMA Ed Hub shed light on these nuanced challenges, while complementary insights from Health Podcast Network explore systemic implications within pain and end-of-life care.
Chronic Pain Management in Palliative and End-of-Life Care
Addressing pain in palliative and end-of-life scenarios is central to improving patient quality of life. Dr Chad Kollas, Medical Director for Palliative and Supportive Medicine at Orlando Cancer Institute, highlights the role of opioid therapy in controlling severe pain, such as cancer progression or other life-limiting conditions. He emphasises that low-dose opioid therapy can significantly reduce distressing symptoms, including dyspnoea associated with end-of-life conditions like emphysema or heart failure.
Nuances Between Palliative and Hospice Care
Dr Kollas notes a key distinction between general palliative care and hospice care, which is federally defined to serve patients within their last six months of life expectancy. While both incorporate opioids to manage pain, each takes a tailored approach based on patient prognosis. For example, opioids like methadone and oxycodone can be adjusted in dosage to optimise relief while balancing safety.
The Intersection of Pain Management and Opioid Use Disorder
A significant challenge arises at the overlap of chronic pain and OUD. Many patients straddle these conditions, facing societal stigma that complicates access to treatment. Dr Kollas shares a poignant scenario involving a stage-four pancreatic cancer patient who also struggled with heroin use. Integrated care, involving methadone for both pain management and opioid dependency, enabled the patient to reconcile with his family and achieve a higher quality of life before passing.
Similarly, biases against controlled opioid use are evident within certain patient populations, influenced by widespread coverage on opioid risks. For instance, a breast cancer patient hesitant to use fentanyl patches eventually found her quality of life vastly improved after overcoming misconceptions. Such barriers underscore the need for nuanced pain management practices informed by patient education.
Unintended Consequences of Opioid Policies
Policy Shifts and Reduced Accessibility
Efforts to curtail opioid misuse, notably through reduced prescribing and manufacturing quotas, have created a double-edged sword. Policies like the 2016 CDC Guidelines initially sought to minimise addiction risks. However, this approach inadvertently restricted access for patients genuinely requiring pain relief, particularly those in end-of-life care or battling chronic conditions.
The Role of a Dangerous Supply Chain
Dr Kollas highlights that dwindling prescription access has driven some patients to acquire opioids through unsafe channels. Counterfeit medications often laced with illicit fentanyl aggravate overdose risks, shifting the crisis toward dangerous, unregulated supplies. He recounts that efforts targeting “pill mills” in Florida achieved reductions in diversion but inadvertently expanded the prevalence of unsafe substitutes like heroin and fentanyl analogues.
Emerging research from Health Podcast Network supports these observations, indicating a parallel rise in illicit fentanyl overdose deaths despite declines in prescription rates.
Assessment and Management of Patient Pain
Pain Subjectivity and Cultural Factors
Pain assessment remains an essential yet subjective component of care. Symptoms vary across individuals, sometimes influenced by sociocultural factors. For instance, an Amish farmer experiencing chest pain delayed treatment due to cultural norms diminishing visible pain responses, masking a severe cardiac event. Anxiety and catastrophic thinking, common among cancer patients in severe pain, often exacerbate symptom perception, creating a psychological feedback loop.
Pain Scales and Shared Decision-Making
While the widely used numerical pain scale (0–10) remains the gold standard, Dr Kollas emphasises its inherent limitations. Effective care relies on multimodal pain management, detailed patient dialogue, and shared decision-making, particularly when sensitive adjustments involve opioids.
Palliative Sedation Principles
Palliative sedation provides relief for patients experiencing intractable suffering, particularly near the end of life. Ethical considerations focus on proportionality—administering the lowest effective opioid dose to alleviate distress while minimising risks. Dr Kollas recounts treating an ALS patient choosing to discontinue ventilatory support, guiding his care with low-dose morphine to provide comfort without hastening death, demonstrating ethically sound practices.
Navigating Pain in Patients with Opioid Use Disorder
Balancing the needs of dying patients with OUD requires integrating risk assessments with traditional pain management. Tools like prescription drug monitoring programmes (PDMPs) assist in verifying medication histories, ensuring treatments address both misuse risks and pain relief. Contextual evaluations of aberrant use further guide care; not every premature medication refill signals misuse—it may instead reflect unaddressed pain.
Collaborative Models and Policy Recommendations
Shifting Towards Right Prescribing
A shift away from opioid reductionism towards “right prescribing” practices is crucial. Patients dependent on opioids for legitimate needs often face abrupt discontinuation or inappropriate tapering, increasing their vulnerability to mental health declines or illicit substance use. National groups like the American Medical Association emphasise moving beyond reduction metrics to implement person-centred prescribing aligned with individual contexts.
Expanding Outpatient Palliative Integration
Randomised control trials affirm that timely outpatient palliative care improves clinical outcomes, reduces healthcare costs, and limits unnecessary aggressive interventions. Dr Kollas asserts that broader access to interprofessional care models addressing psychological, social, and existential needs complements pain care, particularly in dying patients.
Source: AMA Ed Hub
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