Pain Management Part 2 Use of Adjuvants. John Mulder, MD, FAAHPM Vice President of Medical Services Faith Hospice Director, GR MEP Palliative Medicine Fellowship Program. Coanalgesic Drugs (Adjuvant Therapy).
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Pain Management Part 2Use of Adjuvants John Mulder, MD, FAAHPM Vice President of Medical Services Faith Hospice Director, GR MEP Palliative Medicine Fellowship Program
Coanalgesic Drugs (Adjuvant Therapy) • Definition: Drugs which enhance analgesic efficacy of opioids, treat concurrent symptoms that exacerbate pain, or produce independent analgesia for specific types of pain. • Early use optimizes comfort and function by preventing or reducing side effects of higher doses of opioids
Coanalgesic Drugs (Adjuvant Therapy) • Most amenable cancer pain syndromes • Bone metastases • Neuropathic pain • Visceral distention • Most commonly used coanalgesic drugs • NSAIDs • Corticosteroids • Antidepressants • Anticonvulsants
Bone Metastases - Adjuvants • NSAIDs • Steroids • Decadron 4mg BID, titrate • Bisphosphonates • Zometa, Aredia • Radioisotopes
Neuropatic Pain – Adjuvants • Tricyclic antidepressants • Anticonvulsants • Steroids
Alternative/Adjuvant Medications • NSAIDs • Antidepressants • TCA - Elavil, gold standard; desipramine • SSRI - Paxil only one shown effective thus far; Serzone, Effexor promising • Psychostimulants - dietary caffeine, Ritalin, amphetamines
Alternative/Adjuvant Medications • Neuroleptics • Benzodiazapines (watch for sedation) • Anticonvulsants - especially for neurogenic pain (Neurontin) • Baclofen Steroids - high dose, short term/low-dose, long term for bone or neurogenic pain Antihistamines
Alternative/Adjuvant Medications • Steroids - high dose, short term/low-dose, long term • Antihistamines (Benedryl, Vistaril) • Alpha-2-adrenergic stimulants (Clonidine) • Cannabanoids
Alternative/Adjuvant Medications • Capsaicin • Colchicine • Thalidomide • Ketamine • Lidocaine • Dextromethorphan - (no guaifenesin or alcohol) - 30 mg BID - 1 g/d (400 - 600 mg/d usual )
Narcotic Resistant Pains • Headaches • Muscle Spasm • Tenesmoid (Bowel / Bladder) • Incident to movement • Decubitus • Deafferentation
Deafferention Pain • Type I Complex Regional Pain Syndrome A syndrome characterized by severe burning pain in an extremity accompanied by sudomotor, vasomotor, and trophic changes in bone without an associated specific nerve injury. ... • Complex Regional Pain Syndromes Conditions characterized by pain involving an extremity or other body region, HYPERESTHESIA, and localized autonomic dysfunction following injury to soft tissue or nerve. The pain ... • Reflex Sympathetic Dystrophy Syndrome A syndrome characterized by severe burning pain in an extremity accompanied by sudomotor, vasomotor, and trophic changes in bone without an associated specific nerve injury. ...
Non-pharmacologic Interventions • OMM • Acupuncture • Acupressure • Massage Therapy • Music Therapy • Hypnosis • Relaxation
Unwarranted / Exaggerated Fears • Respiratory Depression • Addiction • Rapid Tolerance • Regulatory Reprisal
Opiate Side Effects: Constipation • Most common side effect - expected • Mediated spinally and in GI tract • Decreased peristalsis & decreased intestinal secretions • Tolerance does not readily occur • Treat with peristaltic agent and softeners - prophylactically
Opiate Side Effects: Pruritis • Caused by opioid induced histamine release • Tolerance generally develops quickly • Difficult cases may require a change in opioid • Usually treated with transient use of antihistamines
Opiate Side Effects: Somnolence / Sedation • Common, but tolerance typically develops within a few days • Sedation varies with opioid and dosing schedule • Additive effects with other cerebral depressants • Decrease or discontinue other cerebral depressants • Concurrent use of Dextroamphetamine or Methylphenidate is helpful, but tachyphylaxis is common
Opiate Side Effects: Hallucinations / Confusion • Less common, but may occur especially in older patients • Often an indication of excess dosing • Try dose reduction or different opioid
Opiate Side Effects: Nausea / Vomiting • Occurs in 50 – 65% of patients on oral morphine • Varies with drug and route • Usually easy to control, occasionally severe and difficult to control
Opiate Side Effects: Urinary Retention • Opioids increase smooth muscle tone (sphincter) • May also cause bladder spasms • Try changing opioids or insertion of catheter
Opiate Side Effects: Myoclonus • Can occur with all opioids • Typically due to high doses and/or dehydration • Long half-life metabolites are typically implicated • Reduce dose, change opioids, change routes and/or hydrate patient
Opiate Side Effects: Respiratory Depression • Cause of death in opioid overdose • Tolerance develops rapidly • Rarely a concern with appropriate dose escalations • If accidental overdose occurs in a patient chronically receiving opioids, dilute Naloxone 1:10 and titrate very carefully to reverse respiratory depression without precipitating withdrawal or reversing analgesia