Teaching about methadone use is crucial
Drug therapy for pain management and end-of-life care traditionally has not been a formal priority in medical education, so hospices often run into obstacles when trying to obtain the most effective and efficient pain medications, experts suggest.
"A lot of physicians have never been exposed to the drugs we use in our area of health care, and there is a lot of prejudice against those drugs based on what clinicians hear from drug manufacturers," says Phyllis Grauer, PharmD, president of Palliative Care Consulting Group of Dublin, OH. "Our focus is on patient care and education and explaining the usefulness in this specific time of a patient’s life for medications they have not had a comfort zone with previously."
Some hospices will provide free pain consultation for people who are chronically ill and moving toward terminal illness, says Jeffrey Lycan, RN, president and chief executive officer of the Ohio Hospice & Palliative Care Organization in Upper Arlington. "They’ll offer suggestions to these patients’ physicians, and sometimes those patients are at a point where they need to be hospice patients, and sometimes they are not," Lycan says. "We work with patients and move the care along when other barriers have been placed in front of them and they’re not getting the appropriate standard of care for pain therapy."
Hospices often find that access to the necessary pain drugs is hampered by a lack of education on the part of patients, their families, and physicians, Lycan says. "On the one hand, we want to obtain zero pain, but there is an art to providing enough pain medication so that a patient is able to function," Lycan says. "The goal is to assess the right level of pain medication for a patient." To achieve this outcome, hospices must teach patients and their caregivers that they shouldn’t worry about whether a hospice patient will become addicted to pain medication, Lycan says.
Likewise, physicians too often worry about federal investigators looking over their shoulders when they prescribe certain medications because they are uninformed about the legal restrictions for prescribing these drugs, he notes. "A lot of doctors don’t want to deal with pain medications and want pain specialists to deal with it," Lycan says. "But there are not enough pain specialists to treat all of the people in pain."
Hospices need to inform physicians about the perfectly legal and acceptable ways to prescribe pain medications to hospice patients and also to reassure physicians that hospice nurses have been thoroughly trained to handle pain medications, Grauer says.
Through education, hospices also can teach nurses about the costs of drugs and why one particular type of pain medication would be preferable to another because of its cost or its effectiveness in handling pain, Grauer explains. "We teach hospice nurses how to communicate with physicians such that the physician knows that we’re not just looking at cost or telling the physician what to do," Grauer says. "We tell physicians that the best medication to do the job is the one that’s the most cost-effective, and here’s why."
Make specific observations
It’s also important to teach nurses how to communicate the patient’s symptoms to physicians in a way that enables the doctor to recommend specific drugs, Grauer adds. For example, the nurse would see that a patient is nauseous and has been vomiting. The nurse might explain to the physician that the patient appears to have gastric stasis and that the hospice would like to recommend the patient be prescribed metoclopramide because it’s a more specific drug that is appropriate for the type of nausea the patient has experienced with other medications, Grauer says. "That way, the physician can feel comfortable that there was some thought and good assessment put into that recommendation," she says. "It puts their minds at ease that they can trust the nurse to be their eyes and ears."
Hospices might have to give special consideration to training staff and physicians about using methadone for pain management. "One of the things our organization does is use a lot of methadone in our recommendations," Grauer says. "It’s a drug that’s difficult to prescribe and adjust because it requires a lot of vigilance, so we work with physicians and nurses to adjust that drug."
As a result, patients often have an incredible response to methadone when it’s used correctly, Grauer says. "It provides a lot of benefits that the typical pain medications do not," Grauer says. "And because we oversee its use, it gives a comfort level to the physician and nursing staff."
When compared with fentanyl transdermal (Duragesic) patches and controlled-release oxycodone HCI (OxyContin), methadone is very inexpensive, and in most cases patients get better control of their pain with fewer side effects, Grauer notes. The drawback is that methadone is a drug with a lot of patient variability, and if it’s not dosed correctly, it can cause considerable toxicity, including overdose, she says. "It accumulates in the body if you don’t adjust the dose over time, so you can’t just have a physician say, Let’s put him on methadone every four hours and call me in a month,’" Grauer says. "It takes a week of careful monitoring and adjusting to get the patient on a good dose."
However, the cost savings of the drug make the extra nursing care well worth the expense, Grauer says. "Someone on the hospice team is seeing the patient on a regular basis throughout that week anyway," she says. "And if we get the patient stable with fewer side effects and a better quality of life, and the cost is 10 to 15 times less than with other drug therapies, then you can balance it out."
So it’s worth the effort to educate nurses about the use of methadone and to show physicians how the hospice is prepared to handle that drug, Grauer says.