05/17/2018
Great post by our blogger Dr. Faustino Agustin Gonzalez. He writes about the intersection between opioids, palliative care, and safety. Read and share…
While opioids (narcotic medications such as morphine, oxycodone, Dilaudid) can have devastating effects when not used properly, they also have significant therapeutic value. They are very effective for the management of visceral(organ) pain. In fact, they can also be used for managing severe difficulty with breathing in terminally ill patients. Many people feel that there is a tradeoff between symptom control, which results in increased quality but perhaps also a shorter life. Also, my non-Palliative Medicine colleagues often remark on the ethical slippery slope of combining these medications and potentially accelerating the dying process. There have been several peer-reviewed studies that show the relatively low risk of respiratory depression with increasing doses of opioids in patients who have developed tolerance. Nevertheless, with the very real opioid crisis that is flagellating our country, many clinicians are fearful of prescribing these drugs.
One of the primary mandates of palliative care is symptom control. This may require, particularly at the very end of life, using several drugs in order to assuage multiple symptoms(pain, nausea, restlessness). These drug combinations have a real potential for increasing fatal side effects. While the principle of double effect -- using dose of medications to relieve a symptom, even if they cause death -- is well recognized and supported by ethical principles and upheld by the Supreme Court, one finds him/herself wondering if the treatment being prescribed is not hastening death, especially at night when there is an increased risk of respiratory depression.
A study recently published in the Journal of Pain and Symptom management (Vol. 55 No.1 January 2018) looked at this issue. They retrospectively reviewed the care provided to 765 patients admitted to hospice in Croatia. They wanted to determine if combining opioids with medications used to treat anxiety (drugs related to Va**um) and agitation (antipsychotics; by reducing symptoms of delirium) increased mortality, particularly at night. What they found, similar to other studies, was that not only did these patients not die faster, even at night, but that they had a slightly longer survival than patients whose symptoms were not aggressively managed.
The value of this study is that, because it involved a large number of patients, it validates others that had a smaller sample but reached similar conclusions. Additionally, it helps to dispel myths about hospice and hastening death.
As I said above, we are in the midst of an opioid misuse crisis. However, we need to underscore misuse. When well-trained specialists use these medications, alone or in combination, the likelihood of hastening death is minimal. Even when the greater goal of symptom control at whatever cost is our guiding principle, the fact is that these medications can be safely used and both, symptom control and quality of life, can be achieved without accelerating the dying process.
