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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

Pharmacological Management of Pain

Frank Ferris, MD

Charles F. von Gunten, MD, PhD

epidemiology cancer pain
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 pain3
Epidemiology-Cancer Pain
  • Causes of Pain
  • 70% related to cancer
  • 25% cancer treatment
  • 5% unrelated
  • 70-90% relieved with oral analgesics
epidemiology other pain
Epidemiology-Other Pain
  • AIDS
  • 40-60%
  • Chronically Ill elderly
  • 60-80%
assessment of pain
Assessment of Pain
  • Leading cause of poor pain management
  • Location and Radiation
  • Severity
  • Timing
  • Exacerbating and Relieving
  • Effects on Activity
  • Previous Therapy
pathophysiology
Pathophysiology
  • Nociceptive
    • intact, normally functioning nerves
    • somatic or visceral
  • Neuropathic
    • disrupted functioning of nerves
    • surgery, infection, pressure, drugs
total pain
Total Pain
  • Physical
  • Psychological
  • Social
  • Spiritual
management strategies
Management Strategies
  • Pharmacological
  • Physical
  • Neurolytic
  • Cognitive-Behavioral
  • Intraspinal
acute vs chronic pain
Acute vs Chronic Pain
  • Acute
    • less than 6 weeks
    • related to discernible incident
  • Chronic
    • more than 6 weeks
    • ongoing pathophysiology
  • Intractable
    • non-remediable cause
who 3 step ladder
WHO 3-step ladder

3severe

Morphine

Hydromorphone

Fentanyl

Methadone

Oxycodone

2 moderate

A/Codeine

A/Propoxyphene

A/Oxycodone

1mild

ASA

Acetaminophen

NSAID’s

routes of administration
Routes of Administration
  • Oral
  • Rectal
  • Buccal
  • Transcutaneous
  • Subcutaneous
  • Intravenous
analgesic dosing
Analgesic Dosing
  • Chronic Pain
    • Around-the-Clock
    • Breakthrough doses prn
  • Acute Pain
    • prn dosing
analgesic dosing13
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
titration
Titration
  • Five half-lives to reach steady-state
  • Change routine dosing every 24 hr.
sustained release analgesics
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)
breakthrough dosing
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
common opioid side effects
Common Opioid Side-Effects
  • Constipation
  • Nausea/Vomiting
  • Drowsiness
  • Dry Mouth
  • Sweating
  • Tolerance develops to all in 5-7 days except constipation
uncommon side effects
Uncommon Side-Effects
  • Dysphoria/Delirium
  • Bad dreams/Hallucinations
  • Pruritus/urticaria
  • Urinary Retention
  • Myoclonus/seizures
  • Respiratory Depression
opioid side effects
Opioid Side-Effects

Addiction = Physical Dependence

Out of control

Inappropriate

Preoccupation

Diminished QOL

Abstinence Syndrome

pharmacological tolerance
Pharmacological Tolerance
  • Diminished effect with repeated dosing
  • Uncommon in chronic pain
  • Not clinically limiting
  • Most common reason for increased dose is increased pain
adjuvant pain medicines
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
pain syndromes
Pain Syndromes
  • Neuropathic Pain
  • Bone Pain
adjuvant analgesics
Adjuvant Analgesics
  • Anti-inflammatory
    • NSAIDs, Steroids
  • Tricyclic Analgesics
    • amitriptyline, imipramine
    • nortriptyline, desipramine
  • Antiepileptics
    • carbamazepine, valproate, gabapentin
  • Antispasmodics
    • diazepam, baclofen
    • scopolamine