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Managing End-of-Life Pain In An Opioid Crisis

Managing End-of-Life Pain in an Opioid Crisis

Intense pain is a common feature of terminal disease near the end of life. Fortunately, hospice is very good at pain management. Hospice can manage symptoms effectively for most patients. Sedatives and high-dosage opioids are common in hospice treatment.  Without them, hospice’s ability to manage pain so effectively could be compromised, but doctors have raised questions about the appropriateness of high-dosage opioids for patients already weakened by advanced disease.

[Here we review the scientific evidence, which discusses people in general. This cannot be construed as individual medical advice. Hospice medications should only be taken under the prescription of a doctor, physician’s assistant, or nurse practitioner.]

The Opioid Crisis

In October 2017, the White House declared the opioid crisis a national Public Health Emergency. Doctors are heeding the call to be mindful of over-prescription. This includes looking for alternatives before prescribing opioids. However, hospice patients are different. Long-term addiction is not a likelihood among these patients. End of life is a very important time of life, and the quality of that time becomes an imperative.

Do Opioids Shorten Life for Hospice Patients?

With long-term addiction not being a prevailing concern in hospice, focus has moved to the trade-off between length of life and quality of life. Since the 90s, authorities have reasoned that opioid side-effects would hasten death.1-5 However, direct studies measuring this were largely not available to these authors. The concerns were theoretical.

Hospice Lengthens Life

Counteracting those concerns somewhat was the well-established fact that hospice does not shorten life. In fact, hospice lengthens life by days to months.6-14 Since hospice relies on opioids for pain control, could that medicine really be shortening life?

Opioids Can Lengthen Life for Hospice Patients

It turns out that the theories were wrong. Over the past twenty years, a conclusive body of scientific evidence has emerged. High-dosage opioids do not shorten life for hospice patients.16-18 Researchers have measured the amount prescribed, the timing, and several other factors. The high-dosages of opioids often seen in hospice did not shorten life. In fact, in one way, the opioids lengthened life. When patients had their dosages increased to the amount needed to control pain during hospice, their survival improved 54% (14 days versus 9.1 days).

Do Opioids Plus Sedatives Shorten Life for Hospice Patients?

With the debate about opioids in hospice settled, a more recent, theoretical concern arose.19 Hospice often uses opioids in combination with sedatives and anti-anxiety meds. Each of these categories of drugs have the side-effect of reducing breathing. It occurs more often at night. The prescriptions are generally safe in this regard, but could their combination shorten life for patients already weakened by advance disease?

Opioids Combined with Sedatives Lengthen Life for Hospice Patients

A study recently published in the Journal of Pain and Symptom Management finds that the opposite is true.18  They studied prescriptions of these drug categories: opioids, antipsychotics, and anxiolytics. In hospice, these drugs alone or in combination did not increase the percentage of nighttime deaths. In fact, the combination of opioids and sedatives correlates with survival improving more than 100% (5-day average survival to 11-day average survival).

The exact reason that hospice correlates with survival improving by days to months has not been established. Hospice does not try to lengthen life or shorten life. Hospice only works to improve quality of life for patients and families during a very important time. Concerns over opioids and their combination with other symptom-relieving drugs have been addressed. In fact, the improved survival associated with these drugs may shed light on part of the reason people in hospice live longer. Effective symptom management may be part of how hospice lengthens life.


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