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Active Dying Process
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Opioid Resistant Pain
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You have heard a lot about the importance of pain relief and the basic principles underlying good pain management during your first two years of medical school.

Now you are ready to approach this knowledge in a more patient-focused way: to learn to assess and treat a patient in pain.

This module is designed to help you get the knowledge and skills you will need for this part of patient care:

1. First, you will review this self-instructional module and answer clinical case-based questions about the material.

2. Then you will take the pass/fail post-test at the end of the module.

3. Finally, you will have the opportunity to clarify any areas that remain unclear and to discuss pain relief in a case-management context with an expert in the seminar meeting for this core competency.

This module addresses pain management in the terminally ill patient with a focus on the use of opioids, the cornerstone of pain relief for these patients. For this patient population, there is NO controversy about the use of opioids. [The appropriate role of opioids in the care of patients with chronic pain but without a shortened life expectancy is controversial and unclear. It will NOT be addressed in this module.]

Almost every doctor will care for dying patients, and the basic skills of assessment and management of pain in terminally ill patients are ones that every physician should have.

When it comes to relieving pain in the terminally ill, “be the doctor that you would like to have.”* In other words, provide the kind of care that you would like to receive yourself or have your family member receive. For most of us, that includes skilled and compassionate pain relief. *Educating Physicians on End-of-Life Care (EPEC) Project

1. Understand the importance of pain management in the terminally ill.

2. Know the key steps of pain assessment in advanced illness.

3. Know the pharmacology relevant to opioid treatment of pain in terminally ill patients.
  • Know the WHO ladder approach to pain management
  • Understand the use of nonopioids
  • Opioids:
    • Understand the pharmacokinetics, dosing, titration and recognition of opioid allergy
    • Distinguish the "mild" opioids: codeine, hydrocodone, oxycodone
    • Be familiar with the "major" opioids: morphine, meperidine, hydromorphone, fentanyl, methadone
  • Know how to use an equianalgesia table.
4. Understand the routes of administration available for opioids, and know the major advantages and disadvantages for each.

5. Identify and effectively prevent/treat common opioid side effects.

6. Understand how to approach pain management during the active dying process.

7. Recognize the distinctions between tolerance, physical dependence and addiction, and address related concerns for patients, family members and otherhealth care providers.

8. Understand how to assess patients with opioid-resistant pain and identify what types of medication may be helpful to them.

9. Understand the role of consultation in pain management in advanced illness.


* Developed by :

Karen Ogle, M.D.
College of Human Medicine
Michigan State University

    Instructional and
    Interaction Design by:

    Geraud Plantegenest, M.A
    Blended Curricular Learning Resources Group (B-CLR)

    Last updated: February 2010

    * with materials originally prepared in 1997 by: Karen S.Ogle. MD., Kathryn Lovell, Ph.D.,
    Heather Zaluski, M.A., MD.

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