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Palliative Wound Care

May 26, 2022

Articles are provided as informational purposes only and are not intended to constitute medical advice.

Medication protocols are subject to patient’s medical provider’s authorization.

There are many types of chronic, non-healing wounds. These include pressure ulcers, diabetic ulcers, arterial insufficiency ulcers, venous ulcers, and malignant wounds.


Pressure ulcers are the most common type of wound we encounter as patients decline, become bed bound, and approach end-of-life. Stage 1 and 2 pressure ulcers cause superficial skin changes, and Stage 3 and 4 pressure ulcers affect the deep tissue framework.¹ Pressure ulcers should be staged depending on damage and presence of certain characteristics. It is important to note that if a wound is healing, reverse staging is not done. If a patient has a stage 3 ulcer that is getting better, we would say that the patient has a “healing” stage 3 pressure ulcer.²


A patient’s initial assessment should include a review of their skin and existing wounds, if any, and an assessment of the risk factors that are affecting wound healing. The Braden Scale for Predicting Pressure Sore Risk is one tool used when assessing patients. It is based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Keep in mind, most tools used to predict risk do not account for end-of-life decline, so hospice/palliative care patients may be at greater risk than the scales show.³ Other risk factors for chronic non-healing wounds include obesity, tobacco use, vascular issues, diabetes, elderly, radiation therapy, poor self-care, alcohol use, and neurological issues. After the initial assessment, a plan should be developed that aligns with the patient and family’s goals. If there are emotional or spiritual issues that are contributing to poor self-care or alcohol/substance abuse, consider calling on other members of your multi-disciplinary team (i.e., social worker or clergy) for assistance. Therapy goals, which aim to improve quality of life, should be based on patient prognosis, patient factors, heal-ability of existing wound, type of wound, and patient and family wishes. Goals should include preventing new wounds or worsening of existing wounds, prevent/relieve distressing symptoms, reduce discomfort, reduce risk of infection, bleeding, and odor.³


The TIME mnemonic can help us improve wound care. 

If a wound has non-viable, deficient tissue, it may need to be debrided. However, stable eschar should be painted with Betadine® and never be debrided.¹²  There are many types of debridement techniques including mechanical, autolytic, enzymatic, sharps, surgical, and biologic.¹⁰ Many types of debridement are not appropriate and do not align with goals of care in hospice patients. There are some non-healable wounds that should NOT be debrided. These include arterial wounds in people with Peripheral Artery Disease (PAD) (stable dry gangrene, dry ischemic wound), wounds at risk for bleeding, malignant or inflammatory wounds, lower limb pressure ulcers if arterial insufficiency is present, and wound on patients who are acutely palliative.¹⁰   Most hospice patients have non-healable wounds that should only be debrided if necessary to manage bacterial burden, exudates, and odor.¹⁰


To promote health of the wound, moisture balance must be maintained. The correct dressing will help with this. Dressing choice is based on drainage, non-stick vs absorbent, as well as other factors. Dead space, undermining, and tunneling must be loosely packed or filled with an appropriate dressing. The table below shows the different dressing categories, examples, descriptions, and uses.

Re-evaluate the wound care plan within 2 weeks or if issues arise, or if there are changes in the patient’s condition or patient/family goals. Looking at the edge of the wounds aids in evaluation. Healthy wound edges are attached open and migrating/contracting. Non-healing edges don’t advance or are undermined. Improperly dressed wounds may get tunneling, undermining, and rolled edges. Keep in mind that some patients and family may have difficulty with compliance or procedures and need additional education and support. 


Possible wound complications include pain, bleeding, odor, and infection. Moistening dressings before removal, using non-stick dressings, and doing less frequent dressing changes can all help with pain. Using lidocaine 2% gel topically during wound care and/or pretreating with oral morphine or another oral narcotic 30-60 minutes prior to wound care can also help. For pain after dressing changes, consider applying a small amount of viscous lidocaine to the dressing side that contacts the wound. 


Malignant wounds are associated with a greater risk of bleeding than other types of wounds. If bleeding is anticipated, it should be discussed with the patient and family, and a plan should be in place. Dark basins, towels and bed linens (not red) can be used to minimize the impact of bleeding. Bleeding can be traumatic for the patient and family. Consider calling on other team members to help provide emotional support if needed. When a wound is at risk for bleeding, use gentle irrigation to cleanse the wound⁴ and stop anticoagulants including aspirin³. Avoid unnecessary dressing changes and debridement. Soak dressings with warm normal saline prior to removal if they adhere to the wound¹³ and use non-stick dressings⁴. If bleeding occurs, calcium alginate dressings can be placed on the wound and direct pressure should be applied for 10-15 minutes. If appropriate, the position can be changed or ice packs can be placed over the wound. Silver nitrate sticks can be used for small localized areas of bleeding. Minimize dressing changes (only changing the dressing if it is saturated with blood). If these methods don’t work, sometimes a sucralfate paste is used to help stop the bleeding.¹³


If wound odor is present, cleanse the wound, treat the cause if possible, and control infection.⁹ Crushed metronidazole (Flagyl®) tablets sprinkled over the wound with dressing changes is an off-label use, but can be effective at controlling odor at a reduced cost. If the wound is in an area where it is hard to sprinkle the crushed metronidazole, it can be mixed with a water-based lubricant and then applied to the wound. For deep tissue infection and odor, oral metronidazole can be used. Honey (Medihoney®) may also be effective for odor, wound pain, and debriding. If these options are ineffective, cadexomer iodine gel or an impregnated dressing (pad) is helpful for odor, beneficial for exudate, and also debrides.⁹ Aromatics can be used in the room to hide the odor. Adsorbents like charcoal (briquettes) or cat litter can be placed discreetly in the room. Baking soda may also be applied between dressing layers. Odor may cause embarrassment, shame, and result in patient isolation.⁹ Multidisciplinary team members can assist in supporting the patient emotionally and spiritually. Taking steps to control odor and talking about it with the patient/family and visitors before they arrive, can be helpful. Chewing spearmint gum, placing peppermint oil under the nose or using Vicks vapor rub can be helpful for the patient and visitors to hide the odor.


Wounds should be continuously assessed for local and systemic infection.¹² Wound swabs cannot diagnose an infection.² All wounds have contamination and many are colonized with bacteria. That does not mean there’s an active infection.¹² Wound cultures are not appropriate for most hospice patients. They can be very painful and are difficult to perform correctly and without contamination. The pus and necrotic tissue in a wound do not indicate the bacteria contained within the tissue. Also, once a culture is obtained, if not delivered to the lab within an hour, must be refrigerated.⁸ 


The NERDS and STONEES mnemonic is a useful tool to assess for superficial and deep infection.

Localized infections can be cleansed with topical antiseptics. Consider chlorhexidine, which has low toxicity, povidone-iodine (Betadine®) if broad spectrum is needed, and acetic acid (vinegar diluted 1:5 to 1:10) for suspected pseudomonas. Some topical antiseptics can interfere with wound healing. If the wound is healable, try to limit use and discontinue once infection has been controlled.⁸ After cleansing, topical antimicrobial agents can be used. Crushed metronidazole⁹ and cadexomer iodine that were used for odor, can also be used for localized infection. If these are not effective, silver dressing can be used for a short time, but it is a more expensive option and can cause tissue toxicity and resistance with longer use.⁸ 


Deep tissue infection may cause further systemic infections. Oral antibiotics can be used to treat systemic infections. The choice to use oral antibiotics depends on if the wound is healable, maintenance or non-healable, and the goals of care. If used, the goal is not to heal the wound, but to control the systemic infection. Expected bacteria in our hospice patients’ wounds are gram positive and negative bacteria including anaerobes. Dual oral therapy is used in order to address all of the different types of bacteria anticipated. The antibiotics used in order of preference are:

  • Amoxicillin/Clavulanate (Augmentin®), plus Trimethoprim/Sulfamethoxazole (TMP/SMX) (Bactrim®)
  • Clindamycin plus Ciprofloxacin
  • Doxycycline plus Metronidazole
  • TMP/SMX (Bactrim®) plus Metronidazole


In summary, it is important to do a thorough assessment of all patients for risk of developing chronic wounds and worsening of existing wounds. The main goal for wound care is to improve quality of life. Using the mnemonics TIME and NERDS & STONEES can help improve wound care. Oral antibiotics should only be considered for wounds with deep tissue or systemic infection, and in cases where treatment is preferred by the patient and family. Members of the multidisciplinary team can help support the patient and family and help increase the quality of life for patients with chronic wounds. 


Written by: Karen Bruestle-Wallace, PharmD, BCGP, RPh


References:

  1. Ayello, E. A. (2014, May 12). Pressure ulcer staging. Pressure Ulcer Staging Quality Initiatives. Retrieved January 14, 2022, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/IRF-QRP-Training-%E2%80%93-PrU-Staging-May-12-2014-.pdf 
  2. Daley, B. J. (2021, April 3). Wound care. Wound Care. Retrieved January 18, 2022, from https://emedicine.medscape.com/article/194018-overview#a5 
  3. Emmons, K. R., Dale, B., & Crouch, C. (2014). Palliative wound care, Part 2: Application of Principles. Home Healthcare Nurse, 32(4), 210–222. https://doi.org/10.1097/nhh.0000000000000051 
  4. Ferris, F., & von Gunten, C. F. (2015, May). #46 Malignant wounds. Palliative Care Network of Wisconsin. Retrieved January 19, 2022, from https://www.mypcnow.org/fast-fact/malignant-wounds/ 
  5. Ferris, F., & von Guten, C. F. (2015, May). Pressure ulcer management: Staging and prevention. Palliative Care Network of Wisconsin. Retrieved January 14, 2022, from https://www.mypcnow.org/fast-fact/pressure-ulcer-management-staging-and-prevention/ 
  6. Kulikov, P. (2018, December 25). Improving Wound Care Using the TIME Framework. The University of San Francisco USF Scholarship: a digital repository @ Gleeson Library | Geschke Center. Retrieved January 19, 2022, from https://repository.usfca.edu/cgi/viewcontent.cgi?article=1177&context=dnp 
  7. Nurses Association of Ontario, R. (2019). Project ECHO Skin and Wound Infection Enabler.pdf. Infection Control. Retrieved January 22, 2022, from https://drive.google.com/file/d/1HdkywiJhQjZt4ObrPf60_rnfKLaScCqu/view 
  8. Nurses Association of Ontario, R. (Ed.). (2016, May). Assessment and Management of Pressure Injuries for the Interprofessional Team. Clinical Best Practices Guidelines. Retrieved January 20, 2022, from https://wound.echoontario.ca/wp-content/uploads/2019/05/RNAO-2016-Pressure-Injury-BPG.pdf 
  9. Patel, B., & Cox-Hayley, D. (2015, August). #218 Managing Wound Odor. Palliative Care Network of Wisconsin. Retrieved January 19, 2022, from https://www.mypcnow.org/fast-fact/managing-wound-odor/ 
  10. Regional Wound Care Program, S. (Ed.). (2015, April 6). Guideline and Procedures: Wound debridement. SWR Wound Care Program. Retrieved January 19, 2022, from https://swrwoundcareprogram.ca/Uploads/ContentDocuments/WoundDebridement.pdf 
  11. Tippett, A. (2018, April 12). The Use of Lidocaine in Managing Wounds. WoundSource Blog. Retrieved January 21, 2022, from https://www.woundsource.com/blog/use-lidocaine-in-managing-wounds 
  12. Vera, M. (2020, May 6). Wound Bed Preparation and Beyond. WoundSource. Retrieved January 18, 2022, from https://www.woundsource.com/blog/wound-bed-preparation-and-beyond 
  13. Winnipeg Regional, H. A. (Ed.). (2021, April). Malignant fungating wounds - WRHA professionals. Malignant Fungating Wounds, Clinical Practice Guidelines. Retrieved January 18, 2022, from https://professionals.wrha.mb.ca/old/extranet/eipt/files/EIPT-013-007.pdf 

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Renal Impairment at End of Life: Dosing Implications for Opioids, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), and Antibiotics

21 Oct, 2022
Renal impairment is relatively common in both the elderly and hospice patients, and it can affect the way medications act in the body in several ways. Most commonly, it results in decreased clearance of renally-excreted medications, leading to accumulation of the drug and/or its metabolites and subsequent adverse or toxic effects. The absorption of oral medications may be reduced in patients with renal impairment due to increased gastric pH and gut wall edema. Uremia caused by renal impairment can increase sensitivity to medications that act on the central nervous system (CNS), as well as increase the risk of hyperkalemia due to potassium-sparing drugs. In addition, uremia can enhance the potential for NSAID-induced edema or GI bleeding. Renal impairment can also lead to edema or ascites, cachexia, dehydration, decreased albumin levels and binding capacity, and decreased tissue binding, all of which can impact the effects of medications. To compensate for these renal impairment-induced changes in drug disposition, the typical actions taken regarding medication administration are to decrease the dose, increase the dosing interval, or a combination of the two. The action that would be recommended depends on the drug and its specific characteristics. There are many medications that require dose adjustment in renal impairment, but here we’ll be discussing just those that are most often seen in hospice. The goal is to make you aware of these common medications (and categories) that often need dose adjustment so they trigger a mental alert for possible follow-up if they are ordered for your patients with decreased renal function. Opioids: Many opioids can accumulate in renal impairment as the parent drug and/or metabolites. Tramadol has a maximum daily dose in all patients, but in patients with a creatinine clearance (CrCL) less than 30 mL/minute, this maximum dose is reduced to 200 mg per day and the dosing interval should be extended to every 12 hours. Morphine renal dose reductions start with a CrCL less than 60 mL/minute, with possible extension of the dosing interval at this point as well. It is typically recommended to start considering alternatives to morphine in patients with a CrCL less than 30 mL/minute, and to avoid it altogether in patients with a CrCL less than 15 mL/minute. At end of life, the benefits of morphine can sometimes outweigh the risks. Because the presentation of renal accumulation-based adverse effects may be delayed, morphine can be used even in severe renal impairment or renal failure when the prognosis is hours to days, or in dialysis patients when death is imminent. Typically, oxycodone and hydromorphone are considered preferred alternatives to morphine in patients with significant renal impairment, although they both have metabolites that can accumulate in renal failure. As a result, the dose of oxycodone should be reduced and the dosing interval increased in patients with a CrCL less than 60 mL/minute, and oxycodone extended-release products should usually be avoided in patients with a CrCL less than 30 mL/minute. Hydromorphone dose reduction is also recommended when CrCL is less than 60 mL/minute; further dose reduction and extension of the dosing interval is recommended for hydromorphone when CrCL is less than 30 mL/minute. Although hydrocodone and its active metabolites may accumulate in renal impairment, there are no dose reductions for hydrocodone/acetaminophen according to the manufacturer’s labeling. Hydrocodone extended-release products (Hysingla ER®, Zohydro ER®) are rarely used in hospice, but dose reductions are recommended in patients with moderate to severe renal impairment. Methadone and fentanyl patch are considered among the safest opioids in renal impairment because they do not have active metabolites. However, renal impairment can still alter how fentanyl moves in the body, so dose reduction is recommended in patients with a CrCL of 50 mL/minute or less. For methadone, dose reduction is not recommended until very severe renal impairment (CrCL less than 10 mL/minute). No dose reductions are recommended for buprenorphine at any degree of renal impairment, and it is generally considered safe in this population. NSAIDs: Examples of NSAIDs that are commonly used in hospice include ibuprofen (Advil®, Motrin®), naproxen (Aleve®), and meloxicam (Mobic®), and as mentioned previously, there are some concerns regarding the use of NSAIDs in renal impairment. According to the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline, prolonged therapy with NSAIDs is not recommended if GFR is less than 60 mL/minute/1.73m² , and NSAIDs should typically be avoided in patients with a GFR less than 30 mL/minute/1.73m². As a general rule, NSAIDs should be used at the lowest effective dose for the shortest time possible in patients with renal impairment. In addition, NSAIDs should be avoided in patients with a high risk for developing acute kidney injury (e.g. volume depleted, elderly, and/or taking other nephrotoxic medications), and should be discontinued if acute kidney injury occurs during use. Antimicrobials: Many antimicrobials require dose reduction and/or extension of the dosing interval in renal impairment. Specific dosing recommendations depend on the antimicrobial in question and the type of infection being treated. When used for multiple doses, the dose of the antifungal fluconazole (Diflucan®) should be reduced in patients with a CrCL of 50 mL/minute or less. Examples of antibiotics commonly used in hospice that need dose adjustment include: sulfamethoxazole/trimethoprim (Bactrim®); fluoroquinolone antibiotics, including ciprofloxacin (Cipro®) and levofloxacin (Levaquin®); certain penicillin antibiotics, such as amoxicillin and amoxicillin/clavulanate (Augmentin®); and some cephalosporins, including cephalexin (Keflex®) and cefdinir (Omnicef®). Nitrofurantoin (Macrobid®, Macrodantin®) also has significant concerns in renal impairment. According to the manufacturer’s prescribing information, it is contraindicated in anuria, oliguria, or significant renal impairment (defined as a CrCL less than 60 mL/minute or clinically significant elevated serum creatinine). However, limited data suggest it is safe and effective for short-term use in patients with a CrCL of 30 to 60 mL/minute, although there appears to be an increased risk of pulmonary adverse events when eGFR is less than 50 mL/minute. In any case, nitrofurantoin should be avoided altogether in patients with a CrCL less than 30 mL/minute, due to the risk of pulmonary toxicity, hepatotoxicity, and peripheral neuropathy. Renal impairment can affect drug disposition in several ways, often increasing the risk of adverse and toxic effects. Whenever you have a patient with renal impairment, evaluate whether they are taking medications that may be cause for concern and require dose adjustment, and remember that hospice clinicians, pharmacists, and drug information resources can help by providing specific renal dosing recommendations. By Joelle K. Potts RPh, PharmD, BCGP REFERENCES: Aging and Kidney Disease. National Kidney Foundation. Available at: https://www.kidney.org/news/monthly/wkd_aging [accessed 8/8/2022] Aronoff GR, Bennett WM, Berns JS, Brier ME, Kasbekar N, Mueller BA, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults and Children. 5th American College of Physicians, Philadelphia, PA; 2007. Renal Impairment. Chapter in: Palliative Care Formulary, 7th Edition (PCF7). Wilcock A, Howard P, Charlesworth S, Eds. Pharmaceutical Press, London, UK. Chapter 17, added April 2017; 715-35. Drug monographs. Lexcomp Online, Lexi-Drugs Online. Waltham, MA: UpToDate, Inc. https://online.lexi.com. O’Connor NR, Corcoran AM. End-stage renal disease: symptom management and advance care planning. Am Fam Physician. 2012; 85(7): 705-10. Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International Supplements. Jan 2013; 3(1). Available at: www.kidney-international.org Macrobid® Prescribing Information. Proctor and Gamble Pharmaceuticals, Inc. Cincinnati, OH. Revised Jan 2009. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020064s019lbl.pdf [accessed 6/13/2022] Macrodantin® Prescribing Information. Almatica Pharma Inc. Pine Brook, NJ. Revised Mar 2013. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/016620s072lbl.pdf [accessed 6/13/2022] 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 updated Beers Criteria® for potentially inappropriate medication use in older adults. JAGS. 2019; 00: 1-21

Buprenorphine for Pain Management: Pros vs. Cons in the Hospice Population

24 Aug, 2022
Buprenorphine is a unique opioid analgesic. It has several benefits (“pros”) for pain management, but it also has a few significant risks (“cons”) that prevent it from being used more frequently in hospice.  For pain management, buprenorphine is available as a buccal film (Belbuca®), a weekly transdermal patch (Butrans®), and an injection solution (Buprenex®). The forms that are most often seen in hospice patients are the buccal film and transdermal patch, which are used routinely as long-acting opioids for chronic pain, and these are the dosage forms we’ll be discussing here. Buprenorphine injection is indicated for acute pain and is not recommended for long-term use, and it is rarely used in hospice. Other dosage forms (monthly subcutaneous injection, 6-month subcutaneous implant, and daily sublingual tablet) are indicated for opioid use disorder and are not FDA-approved for pain management. What makes buprenorphine unique is the way it binds to various opioid receptors. The most commonly used opioid analgesics (e.g. morphine, oxycodone, fentanyl, and hydrocodone) are full mu-opioid receptor agonists, meaning they bind to and activate the mu-opioid receptor. In contrast, an antagonist blocks a receptor by binding to it without activating it; naloxone (Narcan®) is an excellent example of a mu-opioid receptor antagonist. Buprenorphine is a partial mu-opioid receptor agonist, which means that it binds to the mu-opioid receptor but activates it to a lesser degree than a full agonist. In addition to its effects at the mu-opioid receptor, buprenorphine has activity at three other opioid receptors: it is an antagonist at the delta- and kappa-opioid receptors, and a full agonist at the ORL-1 (opioid receptor-like 1; a.k.a. nociceptin) opioid receptor. The Pros of Buprenorphine: Effective for pain. Buprenorphine’s partial agonism at the mu-opioid receptor refers only to its activity level at the receptor, and not to its effectiveness as an analgesic. In fact, buprenorphine’s analgesic effects are comparable to full mu-opioid receptor agonists in a variety of different pain types, including moderate to severe post-operative and cancer pain, osteoarthritis, and chronic low back pain. Buprenorphine is also effective for neuropathic pain. Lower risk of certain opioid adverse effects. Because of buprenorphine’s unique activity at four opioid receptors, it is less likely to cause several common opioid adverse effects. When compared with most full mu-opioid receptor agonists, buprenorphine has a lower incidence of respiratory depression – although, as with all opioids, this adverse effect is still possible. Because buprenorphine is also less likely to produce euphoria, it has less potential for physical dependence and addiction; as such, it is classified as a Schedule III (C-III) controlled substance. In addition, when compared with the extended-release forms of oxycodone, hydromorphone, and oxymorphone, buprenorphine buccal film causes significantly less nausea, vomiting, constipation, dizziness, and somnolence. When buprenorphine is compared to morphine, the differences in adverse effect frequency are less pronounced, perhaps due to the dosage forms evaluated (or not evaluated). When comparing buprenorphine buccal film to morphine (dosage form not specified), buprenorphine appears to have just slightly lower incidences of constipation, somnolence, anxiety, and dry mouth. In a 2018 systematic review and meta-analysis of buprenorphine vs. morphine in acute pain management, the only significant difference in adverse effects identified was that buprenorphine was associated with less pruritis. The dosage forms considered in this review varied but were typically morphine injection vs. buprenorphine injection or sublingual tablet (not the patch or buccal film forms of buprenorphine that we usually see in our hospice patients). Safe in special populations. In addition, buprenorphine is considered safe in populations that we see often in hospice: those with renal impairment, including dialysis; those with mild to moderate hepatic impairment; and the elderly. The Cons of Buprenorphine: High cost. Unfortunately, buprenorphine patch and buccal film are relatively high-cost medications, which makes them much less attractive for use in hospice. Depending on the strength, the average cost for the generic weekly patch ranges from approximately $10 to $28 per day; the average cost for the brand buccal film, which is dosed once or twice a day, ranges from approximately $8 to $19 per film. Dosing limitations and cautions in severe hepatic impairment. A potential concern, especially in hospice patients, is that buprenorphine patch and buccal film both have maximum recommended doses. Also, the dose of the patch should be titrated no more frequently than every 72 hours, while the dose of the buccal film should be titrated no more frequently than every 4 days. Because buprenorphine has primarily hepatic metabolism, there are cautions regarding its use in severe liver impairment; in these patients, the dose of the buccal film should be reduced, and the transdermal patch form is not recommended. The Verdict: There are a number of reasons why buprenorphine patch and buccal film are excellent long-acting analgesics for many patients, especially those who are not approaching end of life. However, the cons can be significant, and buprenorphine is usually not preferred as a first- or second-line option for the majority of our hospice patients because other long-acting analgesics are effective and available at a much lower cost (e.g. methadone, morphine extended-release, and many strengths of fentanyl patch). In addition, the fact that buprenorphine patch and buccal film have maximum recommended doses may become an issue at end of life in patients whose pain is rapidly escalating. Of course, the pros and cons must always be weighed for each patient and their specific situation; no doubt there will be some hospice patients for whom buprenorphine patch or buccal film is an ideal choice. Written by Joelle Potts, PharmD, CGP REFERENCES: Lexicomp Online, Lexi-Drugs Online. Waltham, MA: UpToDate, Inc.; July 23, 2022. https://online.lexi.com. [last accessed 7/23/2022] Buprenorphine Practitioner Resources and Information. Substance Abuse and Mental Health Services Administration (SAMSHA), U.S. Department of Health and Human Services. Programs: Medication-Assisted Treatment (MAT). Last updated 6/24/2021. Available at: https://www.samhsa.gov/medication-assisted-treatment/practitioner-resources [last accessed: 2/5/2022] Become a Buprenorphine Waivered Practitioner. Substance Abuse and Mental Health Services Administration (SAMSHA), U.S. Department of Health and Human Services. Programs: Medication-Assisted Treatment (MAT). Last updated 6/24/2021. Available at: https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner [last accessed: 2/5/2022] Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. U.S. Department of Health and Human Services, Federal Register document number 2021-08961, pages 22439-40; 4/28/2021. Available at: https://www.federalregister.gov/documents/2021/04/28/2021-08961/practice-guidelines-for-the-administration-of-buprenorphine-for-treating-opioid-use-disorder [last accessed 2/5/2022] Pharmacist’s Manual: An Informational Outline of the Controlled Substances Act. EO-DEA154; revised 2020. Drug Enforcement Administration (DEA), Diversion Control Division. Available at: https://www.deadiversion.usdoj.gov/pubs/manuals/ [last accessed 2/28/2022] Pharmacological Treatment. Under: Opioids > Medication Assisted Recovery. Indian Health Service (IHS), Rockville, MD. https://www.ihs.gov/opioids/recovery/pharmatreatment/ [accessed 12/9/2021] Hale M, Garofoli M, Raffa RB. Benefit-risk analysis of buprenorphine for pain management. Journal of Pain Research, 2021:14; 1359-69. Gudin J, Fudin J. A narrative pharmacological review of buprenorphine: a unique opioid for the treatment of chronic pain. Pain Ther. Published online: 28 Jan 2020. Childers JW, Lou K, Arnold R. Fast Facts and Concepts #268. Low-dose buprenorphine patch for pain. October 2020. Available at: https://www.mypcnow.org Davis MP. Twelve reasons for considering buprenorphine as a frontline analgesic in the management of pain. The Journal of Supportive Oncology. Nov-Dec 2012; 10(6): 209-19. Khanna IK, Pillarisetti S. Buprenorphine – an attractive opioid with underutilized potential in treatment of chronic pain. Journal of Pain Research, 2015:8. 859-70. White LD, et al. Efficacy and adverse effects of buprenorphine in acute pain management: systematic review and meta-analysis of randomized controlled trials. British Journal of Anaesthesia. 2018; 120(4): 668-78. Morphine (systemic). Lexicomp Online, Lexi-Drugs Online. Waltham, MA: UpToDate, Inc.; July 20, 2022. https://online.lexi.com. [last accessed 7/23/2022] Butrans® (buprenorphine patch) prescribing information. Purdue Pharma LP, Stamford, CT. Revised March 2021. Available at: https://butrans.com [last accessed 3/15/2022] Belbuca® (buprenorphine buccal film) prescribing information. BioDelivery Sciences International, Inc., Raleigh, NC. Revised March 2021. Available at: https://www.belbuca.com. [last accessed 3/15/2022]

The Use of Medical Marijuana in Hospice and Palliative Care

26 May, 2022
Cannabis (marijuana) has recently garnered significant national attention as more states vote to legalize both medicinal and recreational forms of the substance. Cannabis use in end-of-life care is increasingly being sought by patients, and organizations are caught between strict federal regulations and waning state laws. Many states have legalized marijuana’s medical use and some have recognized its recreational use as well. However, federally, it is still a Schedule I substance. Cannabinoids and the Endocannabinoid System Cannabis exerts its effects on the body by interacting with the endocannabinoid system, which consists of cannabinoid (CB) receptors. There are two main CB receptors in the body, the CB1 and the CB2. CB1 receptors can mainly be found in the brain and spinal cord, whereas the CB2 receptors are mostly located in the periphery. More than a hundred cannabinoids have been identified in the marijuana plant. Of these, tetrahydrocannabinol (THC) and cannabidiol (CBD) have been studied most extensively. THC is thought to interact mostly with the CB1 receptor, whereas CBD seems to have an effect on both the CB1 and CB2 receptors. Furthermore, cannabis can be divided into two primary species: indica and sativa. Indica strains are more CBD dominant, so it binds to CB1 and CB2 receptors, causing increased mental and muscle relaxation. The sativa strain is more THC dominant and is more commonly used for recreational purposes.
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