pain management part 2 use of adjuvants n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Pain Management Part 2 Use of Adjuvants PowerPoint Presentation
Download Presentation
Pain Management Part 2 Use of Adjuvants

Loading in 2 Seconds...

play fullscreen
1 / 22

Pain Management Part 2 Use of Adjuvants - PowerPoint PPT Presentation


  • 147 Views
  • Uploaded on

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).

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

Pain Management Part 2 Use of Adjuvants


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
    Presentation Transcript
    1. Pain Management Part 2Use of Adjuvants John Mulder, MD, FAAHPM Vice President of Medical Services Faith Hospice Director, GR MEP Palliative Medicine Fellowship Program

    2. 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

    3. Coanalgesic Drugs (Adjuvant Therapy) • Most amenable cancer pain syndromes • Bone metastases • Neuropathic pain • Visceral distention • Most commonly used coanalgesic drugs • NSAIDs • Corticosteroids • Antidepressants • Anticonvulsants

    4. Bone Metastases - Adjuvants • NSAIDs • Steroids • Decadron 4mg BID, titrate • Bisphosphonates • Zometa, Aredia • Radioisotopes

    5. Neuropatic Pain – Adjuvants • Tricyclic antidepressants • Anticonvulsants • Steroids

    6. 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

    7. 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

    8. Alternative/Adjuvant Medications • Steroids - high dose, short term/low-dose, long term • Antihistamines (Benedryl, Vistaril) • Alpha-2-adrenergic stimulants (Clonidine) • Cannabanoids

    9. Alternative/Adjuvant Medications • Capsaicin • Colchicine • Thalidomide • Ketamine • Lidocaine • Dextromethorphan - (no guaifenesin or alcohol) - 30 mg BID - 1 g/d (400 - 600 mg/d usual )

    10. Narcotic Resistant Pains • Headaches • Muscle Spasm • Tenesmoid (Bowel / Bladder) • Incident to movement • Decubitus • Deafferentation

    11. 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. ...

    12. Non-pharmacologic Interventions • OMM • Acupuncture • Acupressure • Massage Therapy • Music Therapy • Hypnosis • Relaxation

    13. Unwarranted / Exaggerated Fears • Respiratory Depression • Addiction • Rapid Tolerance • Regulatory Reprisal

    14. 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

    15. 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

    16. 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

    17. 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

    18. 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

    19. Opiate Side Effects: Urinary Retention • Opioids increase smooth muscle tone (sphincter) • May also cause bladder spasms • Try changing opioids or insertion of catheter

    20. 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

    21. 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