Regional Palliative Care Services Fall 2007 Our 6th Newsletter The purpose of this newsletter: transdisciplinary communication tool for palliative care in Northern Health Topics will include: information on drug therapy, symptom management, and psychosocial issues education opportunities contact information for consultation team across Northern Health Who should read this newsletter? Any health professional caring for palliative patients in acute care, residential care, or the home setting. Submissions, ideas, or questions? If you have an article you would like to submit or have a request for a particular article please contact me at the email below. The newsletter will be published 3-4 times annually. Nikki Dahlen, B.Sc.Pharmacy NH Palliative Pharmacist Lead Phone: 250-784-7338 Ext 2490 Fax: 250-784-7309 Email: nicole.dahlen@northernhealth.ca In This Issue. Case Report Pediatric Methadone...Pg 1 NH Nurse Champion CPG s...pg 4 More Education...Pg 5 Contact Information Pg 5 Case Report Provision of Methadone Infusion by a Community Pharmacy for a Pediatric Patient Requiring Palliative Care Background There is an increasing trend towards devolving health care from acute care/institutional settings to the home when suitable. In light of this, our community pharmacy was designed with a clean room and laminar air flow hood for preparing sterile preparations such as intravenous antibiotics or total parenteral nutrition for administration at home. Pharmacy technicians who are hired have completed a pharmacy technician course, at an accredited college, that includes aseptic technique, and all receive in-house training in aseptic technique. The function of the laminar airflow hood is certified annually. Report A 6 year old girl with primary liver cancer and bone and lung metastases was discharged from a tertiary centre for palliative care at home in a small city far from the tertiary centre. Both the pediatric palliative specialist and local family physician were prepared to support SD and her family s wish for her to die at home. Pain control with morphine was inadequate, yet she was quite sedated; breakthrough pain was severe. It was suspected that SD was experiencing a tremendous amount of nerve pain due to cancer involvement in her pelvis. The patient s family physician applied for and was granted permission by the British Columbia College of Physicians and Surgeons to prescribe methadone for pain for this patient. Her daily oral morphine dose was almost 400mg on the last day that she received Issue 6
morphine exclusively. With close follow-up from the specialist, SD was prescribed oral methadone: an initial dose of 5mg, followed by 2.5mg to 5mg every 3 to 4 hours, and morphine for breakthrough doses. Within 36 hours, morphine was discontinued and methadone was used for breakthrough pain as well. In less than 24 hours the family noticed an improvement in pain control and after 3 days the change was dramatic. Her speech became very clear, she was keenly aware of and participated in conversations going on around her, and was able to rest comfortably, including appropriate cycles of deep sleep. Several days after SD had begun methadone, she became paralyzed from the hips down and then from the waist down, which also contributed to an improved level of comfort. She continued with the oral methadone for 3 weeks, until she no longer wanted to swallow the methadone solution and the decision was made to switch her to intravenous methadone. Methods We followed the process for preparing methadone infusion aseptically used by the University of Alberta hospital pharmacy (personal communication*). The family physician applied for a special authority so that the intravenous medications would be paid for by the palliative program of BC Pharmacare. The initial dose was 50mg of methadone in 250ml 0.9% sodium chloride (0.2mg/ml). A pharmacist confirmed that the dosage conversion from oral to intravenous was in the appropriate range. The infusion was run at between 9 and 11ml per hour using a volumetric pump and infused into a central line. Two 2ml syringes of methadone 1mg/ml were prepared for bolus doses when necessary. The concentration was increased to 0.28mg/ml on Day 2 of the infusion. A new bag and 2 syringes were prepared each day because the stability of the infusion beyond 28 hours is not known. On Day 4 the concentration was increased to 0.32mg/ml. SD s pain control was assessed by her parents and by her aunt, a nurse who had primary responsibility for maintaining the intravenous line, pump, and infusion rate. SD stayed in the same prone position for 5 weeks, and although her level of activity never did improve, she was comfortable and mentally in control. In terms of adverse effects she was not constipated, occasionally had vivid dreams, experienced no hallucinations, and developed a face-picking habit (that was distressing for the family). SD received 8 days of methadone infusion, with 5 bolus doses for breakthrough pain, and died at home with her family around her. Discussion Pediatric palliative care is a challenging area for several reasons. The pharmacokinetics of some pain medications differ in children compared to adults, and there are few published studies. Methadone has advantages for treating cancer pain in children, although it is not approved in Canada for this indication. It is a potent opioid with a long pharmacokinetic half-life (12-50 hours) and good bioavailability, is relatively inexpensive, and is devoid of active metabolites that can cause adverse effects. Methadone can cause prolongation of the QT interval and this must be kept in mind if the patient is receiving other medication with this effect. Methadone is hepatically metabolized by cytochrome P450 enzymes (substrate of CYP2C9 [minor], 2C19 [minor], 2D6 [minor], 3A4 [major]; inhibits CYP2D6 [moderate], 3A4 [weak]); therefore, there is potential for interactions with other drugs metabolized by the same pathways. In addition, there is a dissociation between the pharmacokinetic half-life and the pharmacological half-life; frequent monitoring must be done when converting from another opioid to methadone and when making dose changes. Indeed, conversion from another 2 Issue 6
opioid to methadone should only be undertaken by those experienced in its use because dose equivalence with other opioids is not clearly established. Methadone is available commercially in 1,5,10, and 25mg tablets and 1 and 10mg/ml oral solutions. It can be difficult to switch dysphagic patients who are stabilized on oral methadone to another opioid intravenously and maintain pain control. A preparation for subcutaneous or intramuscular, but not intravenous, injection can be obtained via special access from Health Canada. Solutions of methadone for intravenous administration can be prepared in facilities that have the appropriate equipment and trained personnel. For initiating methadone in children, the World Health Organization guidelines recommend 0.2mg/kg orally every 4-8 hours or 0.1mg/kg subcutaneously or intravenously every 4-8 hours (oral:parenteral dose conversion 2:1). While we hope that we will not encounter the situation of a pediatric patient requiring palliative care again, it was satisfying to be able to offer this service and contribute to effective pain management for SD. Pharmacists can play an integral role in palliative care in various ways, such as assisting with conversion from one or a combination of opioids to another or from one route of administration to another, recommending options for adjuvant therapy or for control of adverse effects, and as in this case, compounding alternative dosage forms. Pharmacists with particular expertise in palliative care are also involved in assessing level of pain control and severity of adverse effects. Written by: Lori Bonertz and Nancy Dyck are pharmacists at the Fort St. John Pharmacy and Wellness Centre. Valerie Kantz is the senior pharmacy technician at Fort St. John Pharmacy and Wellness Centre, Fort St. John, B.C. The authors dedicate this article to the memory of SD and to her family, who encouraged us to pursue publishing this case report in the hope that is could help other children in pain. Reproduced with permission from the Canadian Pharmacist Journal, September / October 2007, Vol 140 / No 5. References 1. Capital Health Regional Drug Information Center (RDIC). Recipe Database; Methadone 2mg/ml for injections (online database). Revised May 19, 2004. Available: www.inphonet.ca (accessed July 30, 2007). 2. Lugo RA, Satterfield KL, Kern SE. Pharmacokinetics of methadone. J Pain Palliat Care Pharmacother 2005; 19:3-24. 3. Lexi-Comp Reader Version 2.4.060602, Copyright 2006, Lexi-Comp Ince. PDA database. 4. Ripamonti C, Groff L, Brunelli C, et al. Swithcing from morphine to oral methadone in treating cancer pain: what is the equianalgesic dose ratio? J Clin Oncol 1998; 16:3216-21 5. Repchinsky C, editor. Compendium of pharmaceuticals and specialties. 42 nd ed. Ottawa: Canadian Pharmacists Association; 2007: p1424. 6. Pain in children with cancer: the World Health Organization IASP Guidelines. Available: www.whocancerpain.wisc.edu/eng/12_1 /IASP_guidelines.html (accessed November 13, 2006). 3 Issue 6
Educational Opportunity for Nurse Champions Clinical Practice Guidelines Home and Community Care reminds all Nurse Champions and other interested nurses to participate in a distance education program, a series of eight monthly teleconferences to introduce the remaining Clinical Practice Guidelines (CPGs), facilitated by Lori Amdam, RN, MSN, Nursing Consultant, Gerontology, Harrigan Consulting, Vancouver. Invitations have been going to "nurse champions" within home and community care, mental health services and acute care. From that, interest has spread to home support, physio, and other health care professionals. So far the sessions have been well attended. The primary focus of the teleconference educational sessions is for Nurse Champions and other interested nurses (potential nurse champions) to lead the implementation of the Clinical Practice Guidelines (CPG s). These teleconferences will provide an opportunity to share knowledge and expertise, network with colleagues about issues of importance, and develop strategies for introducing best practice standards in our nursing settings. The first Guideline that was reviewed was Fall Prevention in October 2007. The upcoming schedule will be as follows: November 2007 - End of Life / Palliative Care December 2007 - none January 2008 - Promoting Urinary continence February 2008 - Alcohol and substance use March 2008 - Least Restraint April 2008 - Promoting Nutrition May 2008 - Assessment & Management of Persistent Pain, and, Prevention of constipation June 2008 - Skin Integrity Each CPG topic will be offered three times monthly 1st Thursday - 2 pm to 3 pm (3 pm to 4 pm - mst) 2nd Wednesday - 1pm to 2 pm (2 pm to 3 pm - mst) 3rd Thursday - 2 pm to 3 pm (3 pm to 4 pm - mst) Participants will be asked to register for their preferred dates. If they cannot attend a session, they must ask a colleague to attend in their place. Upon registration, the teleconference call-in number will be forwarded to each participant. Prior to each session, a printable electronic version of the CPG, power point teaching slides and one recent article or relevant material of interest to read before the program will be forwarded by E-mail. Please note that, although this program will review a new CPG each month, there will be no change in the mandate for Nurse Champions to introduce standards in their facilities and programs at an appropriate and manageable pace. There is no cost for participants to enroll in this program and a certificate will be provided at the conclusion. To register for one of the sessions, please contact Mona Kelley by E-mail mona.kelley@northernhealth.ca or by telephone 250-612-4501. *Right now the CPG s are not posted to docushare, but will be part of the new I-Portal development. 4 Issue 6
More Education. Victoria Hospice Medical Care of the Dying Course March 3-7 th, 2008 Victoria Hospice Pyschosocial Care of the Dying and Bereaved Course February 25-29 th, 2008 Victoria Hospice Spiritual Care Course January 26 th, 2008 See www.victoriahospice.org for more information and registration forms Northern Health Iportal On November 26, 2007, Northern Health will launch iportal which replaces our current Intranet site. The palliative care page with be located under clinical resources in this site. For more information about iportal, please e-mail iportal@northernhealth.ca, or contact the ITS Service Desk. To review some of our most frequently asked questions, visit the iportal FAQ. Contact Information Palliative Care Physician Leads Northwest: Dr. Elizabeth (Biz) Bastian (250-877-2462) biz.bastian@northernhealth.ca Northern Interior: Dr. Inban Reddy (250-563-2481) inbred@telus.net Northeast: Dr. Stephen Ashwell (250-782-1186) stephen.ashwell@northernhealth.ca Palliative Care Nurse Consultants Northwest: Smithers: Lynn Shervill (250-877-4410) Lynn.shervill@northernhealth.ca Terrace: Elaine Minifie (250-632-8653) Elaine.minifie@northernhealth.ca Pr.Rupert: Joan Patriquin (250-622-6343) Joan.patriquin@northernhealth.ca Northern Interior: PG: Cathy Czechmeister (250-565-7318) Cathy.Czechmeister@northernhealth.ca Outside PG: Judy Lett (250-649-7961) Judy.Lett@northernhealth.ca Northeast: Sandi Armitage (250-719- 6524) Sandi.Armitage@northernhealth.ca Palliative Care Pharmacist Lead NHA: Nikki Dahlen (250-784-7338 ext 2490) nicole.dahlen@northernhealth.ca Palliative Care Social Work Lead NHA no hire as of yet All information provided in newsletter is in accordance with our endorsed text: Medical Care of the Dying, 4 th Edition, Victoria Hospice Society. 5 Issue 6