This was written by Jeffrey Brown, MD, HMDC, medical director, Parkview Home Health & Hospice.
When deciding to forego aggressive life-prolonging treatments and enroll in hospice care, one of the primary motivating factors is ensuring adequate comfort in the face of a terminal illness. A hospice care team generally focuses on improving a person's quality of life moving forward with an equally aggressive emphasis on adequate symptom management to achieve that goal. While it isn't uncommon to discontinue some (or most) routine or preventative medications, there may also be instances where adding new medicines is necessary to treat various symptoms in the hospice population.
Why opioid use is necessary
Adequate pain treatment is often the most significant concern for individuals facing a terminal condition. Most of us are familiar with treating pain at home using over-the-counter medications such as acetaminophen, ibuprofen or naproxen. While these medications may continue to be helpful, most patients under hospice care will require opioids like morphine, hydrocodone, oxycodone, etc., at some point throughout their illness. While likely not unexpected in diseases such as cancer, this need is common in most patients approaching the end of life. This need may result from extreme debility and musculoskeletal pain, or unmanageable shortness of breath related to end-stage heart or lung disease. In these instances, opioids are often the best for symptomatic treatment.
Providers may also utilize additional medications (or adjuvants) to supplement opioids to improve their efficacy and reduce the amount required for treatment. These could include medicines aimed at reducing nerve-mediated pain, such as gabapentin or steroids, which can assist with skeletal and soft tissue pain. Reducing the total opioid dose may also help limit common side effects like constipation. Laxatives are also typically prescribed to avoid this potential issue, given opioids' propensity to slow bowel motility. Sedation is the other common opioid side effect, which is dose-related and mitigated by adjusting the amount and frequency of medication given.
Understanding the possible side effects
A somewhat unusual characteristic of opioids is the development of tolerance. In this context, tolerance refers to the observation that a person using opioids to treat their pain will require increased doses over time to achieve the same level of pain control. People treated over a long period may require very high doses in comparison to someone who has never used opioid pain medication in the past. This factor plays a role in the selection of opioids, as someone taking these medications for the first time would likely require a "weaker" option like morphine. In contrast, someone who has developed tolerance over time may require a more potent drug like fentanyl or methadone. The presence of decreased kidney and/or liver function will also affect the provider's choice of appropriate pain medication for each individual.
While the potential for abuse and even addiction is real, it is exceedingly rare in the hospice population. Persons with a previous history of addiction to alcohol, illicit drugs, or even gambling may be at higher risk. However, their hospice team will develop individualized strategies to help mitigate that risk while allowing for adequate symptom control. While there is much research regarding the "opioid epidemic" and the dangers of these medications, they still remain both safe and effective when prescribed appropriately by providers specially trained in symptom management.
Final thoughts
Ultimately, the goal of the entire hospice team is to maximize each individual's quality of life while they are under hospice care. To that end, providing patients and families with the tools needed to attend to whatever symptoms may develop is a pillar of quality hospice care. Opioids may well be a necessary (and welcome) addition to that toolbox and can be both safe and highly effective in helping achieve our goal of making every day a good one.
