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Pharmacological Management of Pain PowerPoint PPT Presentation


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Pharmacological Management of Pain. Frank Ferris, MD Charles F. von Gunten, MD, PhD. Epidemiology-Cancer Pain. 30-45% of all patients 75% of those with advanced disease Of those with pain 40-50% moderate to severe 25-35% excruciating. Epidemiology-Cancer Pain. Causes of Pain

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Pharmacological Management of Pain

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Pharmacological management of pain l.jpg

Pharmacological Management of Pain

Frank Ferris, MD

Charles F. von Gunten, MD, PhD


Epidemiology cancer pain l.jpg

Epidemiology-Cancer Pain

  • 30-45% of all patients

  • 75% of those with advanced disease

  • Of those with pain

    • 40-50% moderate to severe

    • 25-35% excruciating


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Epidemiology-Cancer Pain

  • Causes of Pain

  • 70% related to cancer

  • 25% cancer treatment

  • 5% unrelated

  • 70-90% relieved with oral analgesics


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Epidemiology-Other Pain

  • AIDS

  • 40-60%

  • Chronically Ill elderly

  • 60-80%


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Assessment of Pain

  • Leading cause of poor pain management

  • Location and Radiation

  • Severity

  • Timing

  • Exacerbating and Relieving

  • Effects on Activity

  • Previous Therapy


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Pathophysiology

  • Nociceptive

    • intact, normally functioning nerves

    • somatic or visceral

  • Neuropathic

    • disrupted functioning of nerves

    • surgery, infection, pressure, drugs


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Total Pain

  • Physical

  • Psychological

  • Social

  • Spiritual


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Management Strategies

  • Pharmacological

  • Physical

  • Neurolytic

  • Cognitive-Behavioral

  • Intraspinal


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Acute vs Chronic Pain

  • Acute

    • less than 6 weeks

    • related to discernible incident

  • Chronic

    • more than 6 weeks

    • ongoing pathophysiology

  • Intractable

    • non-remediable cause


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WHO 3-step ladder

3severe

Morphine

Hydromorphone

Fentanyl

Methadone

Oxycodone

2 moderate

A/Codeine

A/Propoxyphene

A/Oxycodone

1mild

ASA

Acetaminophen

NSAID’s


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Routes of Administration

  • Oral

  • Rectal

  • Buccal

  • Transcutaneous

  • Subcutaneous

  • Intravenous


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Analgesic Dosing

  • Chronic Pain

    • Around-the-Clock

    • Breakthrough doses prn

  • Acute Pain

    • prn dosing


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Analgesic Dosing

  • For ROUTINE dosing, dose every half-life (t 1/2)

    • Morphine t 1/2 = 3 1/2 hrs

    • Morphine 15 mg po q 4h

  • For TITRATION and BREAKTHROUGH dose every Cmax.

    • Morphine Cmax = 1 hr

    • Morphine 5 mg po q 1h


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Titration

  • Five half-lives to reach steady-state

  • Change routine dosing every 24 hr.


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Sustained-release analgesics

  • Don’t use for titration

  • After dose established, change to sustained-release product for quality-of-life reasons

    • q 12 h (morphine, hydromorphone)

    • q 24 h (morphine)

    • q 72 h (fentanyl)


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Breakthrough Dosing

  • Chronic Pain is rarely rock-stable

  • Breakthrough dose is 10-20% of 24 hr dose

    • MS Contin 60 mg po q 12 h

    • Morphine 10-20 mg po q 1 h

  • More than 2-4 breakthrough doses per day means change the baseline dose


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Common Opioid Side-Effects

  • Constipation

  • Nausea/Vomiting

  • Drowsiness

  • Dry Mouth

  • Sweating

  • Tolerance develops to all in 5-7 days except constipation


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Uncommon Side-Effects

  • Dysphoria/Delirium

  • Bad dreams/Hallucinations

  • Pruritus/urticaria

  • Urinary Retention

  • Myoclonus/seizures

  • Respiratory Depression


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Opioid Side-Effects

Addiction = Physical Dependence

Out of control

Inappropriate

Preoccupation

Diminished QOL

Abstinence Syndrome


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Pharmacological Tolerance

  • Diminished effect with repeated dosing

  • Uncommon in chronic pain

  • Not clinically limiting

  • Most common reason for increased dose is increased pain


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Adjuvant Pain Medicines

  • Drugs added to opioids which given additional or synergistic pain relief

  • Primary Analgesics

    • e.g. tricyclics or aspirin

  • Non-analgesics

    • e.g. steroids


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Pain Syndromes

  • Neuropathic Pain

  • Bone Pain


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Adjuvant Analgesics

  • Anti-inflammatory

    • NSAIDs, Steroids

  • Tricyclic Analgesics

    • amitriptyline, imipramine

    • nortriptyline, desipramine

  • Antiepileptics

    • carbamazepine, valproate, gabapentin

  • Antispasmodics

    • diazepam, baclofen

    • scopolamine


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