education in palliative and end-of-life care - oncology
DESCRIPTION
The. EPEC-O. TM. Education in Palliative and End-of-life Care - Oncology. Project. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. - PowerPoint PPT PresentationTRANSCRIPT
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The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.
Education in Palliative and End-of-life Care - Oncology
The
ProjectEPEC-O
TM
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EEPPEECC
OO
EEPPEECC
OO
Module 2Module 2
Cancer Pain Cancer Pain ManagementManagement
Module 2Module 2Cancer Pain Cancer Pain ManagementManagement
EPEC - Oncology Education in Palliative and End-of-life Care - Oncology
EPEC - Oncology Education in Palliative and End-of-life Care - Oncology
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Overall messageOverall message
Pain management is an Pain management is an essential component of essential component of
comprehensive cancer care.comprehensive cancer care.
Pain management is an Pain management is an essential component of essential component of
comprehensive cancer care.comprehensive cancer care.
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Objectives . . .Objectives . . .
Compare, contrast nociceptive, Compare, contrast nociceptive, neuropathic painneuropathic pain
Know steps of analgesic Know steps of analgesic managementmanagement
Demonstrate ability to convert Demonstrate ability to convert between opioids while maintaining between opioids while maintaining analgesiaanalgesia
Compare, contrast nociceptive, Compare, contrast nociceptive, neuropathic painneuropathic pain
Know steps of analgesic Know steps of analgesic managementmanagement
Demonstrate ability to convert Demonstrate ability to convert between opioids while maintaining between opioids while maintaining analgesiaanalgesia
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. . . Objectives. . . Objectives
Know use of adjuvant analgesic Know use of adjuvant analgesic agentsagents
Know adverse effects of analgesics, Know adverse effects of analgesics, their managementtheir management
List barriers to pain managementList barriers to pain management
Know use of adjuvant analgesic Know use of adjuvant analgesic agentsagents
Know adverse effects of analgesics, Know adverse effects of analgesics, their managementtheir management
List barriers to pain managementList barriers to pain management
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VideoVideo
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General principles . . .General principles . . .
AssessmentAssessment
ManagementManagement
PharmacologicalPharmacological
Non-pharmacologicalNon-pharmacological
AssessmentAssessment
ManagementManagement
PharmacologicalPharmacological
Non-pharmacologicalNon-pharmacological
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. . . General principles. . . General principles
Education – patient, family, all Education – patient, family, all caregiverscaregivers
Ongoing assessment of outcomes, Ongoing assessment of outcomes, regular review of plan of careregular review of plan of care
Interdisciplinary care, consultative Interdisciplinary care, consultative expertiseexpertise
Education – patient, family, all Education – patient, family, all caregiverscaregivers
Ongoing assessment of outcomes, Ongoing assessment of outcomes, regular review of plan of careregular review of plan of care
Interdisciplinary care, consultative Interdisciplinary care, consultative expertiseexpertise
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Pain pathophysiologyPain pathophysiology Acute painAcute pain
Identified event, resolves days–weeksIdentified event, resolves days–weeks
Usually nociceptiveUsually nociceptive
Chronic painChronic pain
Cause often not easily identified, Cause often not easily identified, multifactorialmultifactorial
Indeterminate durationIndeterminate duration
Nociceptive and / or neuropathicNociceptive and / or neuropathic
Acute painAcute pain
Identified event, resolves days–weeksIdentified event, resolves days–weeks
Usually nociceptiveUsually nociceptive
Chronic painChronic pain
Cause often not easily identified, Cause often not easily identified, multifactorialmultifactorial
Indeterminate durationIndeterminate duration
Nociceptive and / or neuropathicNociceptive and / or neuropathic
Wolf CJ. Ann Intern Med. 2004.
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Nociceptive pain . . .Nociceptive pain . . . Direct stimulation of intact Direct stimulation of intact
nociceptorsnociceptors
Transmission along normal nervesTransmission along normal nerves
SomaticSomatic
Easy to describe, localizeEasy to describe, localize
VisceralVisceral
Difficult to describe, localizeDifficult to describe, localize
Direct stimulation of intact Direct stimulation of intact nociceptorsnociceptors
Transmission along normal nervesTransmission along normal nerves
SomaticSomatic
Easy to describe, localizeEasy to describe, localize
VisceralVisceral
Difficult to describe, localizeDifficult to describe, localize
Wolf CJ. Ann Intern Med. 2004.
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. . . Nociceptive pain. . . Nociceptive pain
Tissue injury apparentTissue injury apparent
ManagementManagement
OpioidsOpioids
Adjuvant / coanalgesicsAdjuvant / coanalgesics
Tissue injury apparentTissue injury apparent
ManagementManagement
OpioidsOpioids
Adjuvant / coanalgesicsAdjuvant / coanalgesics
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Neuropathic pain . . .Neuropathic pain . . . Disordered peripheral or central Disordered peripheral or central
nervesnerves
Compression, transection, Compression, transection, infiltration, ischemia, metabolic infiltration, ischemia, metabolic injuryinjury
Varied typesVaried types
Peripheral, deafferentation, complex Peripheral, deafferentation, complex regional syndromesregional syndromes
Disordered peripheral or central Disordered peripheral or central nervesnerves
Compression, transection, Compression, transection, infiltration, ischemia, metabolic infiltration, ischemia, metabolic injuryinjury
Varied typesVaried types
Peripheral, deafferentation, complex Peripheral, deafferentation, complex regional syndromesregional syndromes
Wolf CJ. Ann Intern Med. 2004.
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. . . Neuropathic pain. . . Neuropathic pain
Pain may exceed observable injury Pain may exceed observable injury
Described as burning, tingling, Described as burning, tingling, shooting, stabbing, electrical shooting, stabbing, electrical
ManagementManagement
OpioidsOpioids
Adjuvant / coanalgesics often requiredAdjuvant / coanalgesics often required
Pain may exceed observable injury Pain may exceed observable injury
Described as burning, tingling, Described as burning, tingling, shooting, stabbing, electrical shooting, stabbing, electrical
ManagementManagement
OpioidsOpioids
Adjuvant / coanalgesics often requiredAdjuvant / coanalgesics often required
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Pain managementPain management
Don’t delay for investigations or Don’t delay for investigations or disease treatmentdisease treatment
Unmanaged pain => nervous system Unmanaged pain => nervous system changeschanges
Permanent damagePermanent damage
amplify painamplify pain
Treat underlying cause (eg, radiation Treat underlying cause (eg, radiation for a neoplasm)for a neoplasm)
Don’t delay for investigations or Don’t delay for investigations or disease treatmentdisease treatment
Unmanaged pain => nervous system Unmanaged pain => nervous system changeschanges
Permanent damagePermanent damage
amplify painamplify pain
Treat underlying cause (eg, radiation Treat underlying cause (eg, radiation for a neoplasm)for a neoplasm)
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PlacebosPlacebos
No role for placebos to assess or No role for placebos to assess or treat paintreat pain
No role for placebos to assess or No role for placebos to assess or treat paintreat pain
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WHO 3-stepLadderWHO 3-stepLadder
1 mild1 mild
2 moderate2 moderate
3 severe3 severe
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
Tramadol
± Adjuvants
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
Tramadol
± Adjuvants
ASA
Acetaminophen
NSAIDs
± Adjuvants
ASA
Acetaminophen
NSAIDs
± Adjuvants WHO Geneva, 1996.
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AcetaminophenAcetaminophen Step 1 analgesic, CoanalgesicStep 1 analgesic, Coanalgesic
Site, mechanism of action unknownSite, mechanism of action unknown
Minimally anti-inflammatory effectMinimally anti-inflammatory effect
Hepatic toxicity if > 4 grams / 24 Hepatic toxicity if > 4 grams / 24 hourshours
Increased riskIncreased risk
Hepatic disease, heavy alcohol Hepatic disease, heavy alcohol useuse
Step 1 analgesic, CoanalgesicStep 1 analgesic, Coanalgesic
Site, mechanism of action unknownSite, mechanism of action unknown
Minimally anti-inflammatory effectMinimally anti-inflammatory effect
Hepatic toxicity if > 4 grams / 24 Hepatic toxicity if > 4 grams / 24 hourshours
Increased riskIncreased risk
Hepatic disease, heavy alcohol Hepatic disease, heavy alcohol useuse
Mitchell JR, Potter WZ. Med Clin North Am. 1975.
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NSAIDs . . .NSAIDs . . .
Step 1 analgesic, coanalgesicStep 1 analgesic, coanalgesic
Inhibit cyclooxygenase (COX)Inhibit cyclooxygenase (COX)
Vary in COX-2 selectivityVary in COX-2 selectivity
All have analgesic ceiling effectsAll have analgesic ceiling effects
Effective for bone, inflammatory painEffective for bone, inflammatory pain
Individual variation, serial trialsIndividual variation, serial trials
Step 1 analgesic, coanalgesicStep 1 analgesic, coanalgesic
Inhibit cyclooxygenase (COX)Inhibit cyclooxygenase (COX)
Vary in COX-2 selectivityVary in COX-2 selectivity
All have analgesic ceiling effectsAll have analgesic ceiling effects
Effective for bone, inflammatory painEffective for bone, inflammatory pain
Individual variation, serial trialsIndividual variation, serial trials
Carson LJ, Willett LR. Drugs,1993.
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. . . NSAIDs. . . NSAIDs Highest incidence of adverse eventsHighest incidence of adverse events
GastropathyGastropathy
Gastric cytoprotectionGastric cytoprotection
COX-2 selective inhibitorsCOX-2 selective inhibitors
Renal insufficiencyRenal insufficiency
Maintain adequate hydrationMaintain adequate hydration
COX-2 selective inhibitorsCOX-2 selective inhibitors
Inhibition of platelet aggregationInhibition of platelet aggregation
Assess for coagulopathyAssess for coagulopathy
Highest incidence of adverse eventsHighest incidence of adverse events
GastropathyGastropathy
Gastric cytoprotectionGastric cytoprotection
COX-2 selective inhibitorsCOX-2 selective inhibitors
Renal insufficiencyRenal insufficiency
Maintain adequate hydrationMaintain adequate hydration
COX-2 selective inhibitorsCOX-2 selective inhibitors
Inhibition of platelet aggregationInhibition of platelet aggregation
Assess for coagulopathyAssess for coagulopathy
Peura DA. Cleve Clin J Med, 2002.
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Opioid pharmacology . . .Opioid pharmacology . . .
Conjugated in liverConjugated in liver
Excreted via kidney (90–95%)Excreted via kidney (90–95%)
First-order kineticsFirst-order kinetics
Conjugated in liverConjugated in liver
Excreted via kidney (90–95%)Excreted via kidney (90–95%)
First-order kineticsFirst-order kinetics
Collins SL, et al. J Pain Symptom Manage. 1998.
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Pla
sma
Co
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on
cen
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Pla
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Co
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0000 Half-life (tHalf-life (t1/21/2))Half-life (tHalf-life (t1/21/2)) TimeTimeTimeTime
IVIVIVIV
PO / prPO / prPO / prPO / pr
SC / IMSC / IMSC / IMSC / IM
CCmaxmaxCCmaxmax
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. . . Opioid pharmacology . . .. . . Opioid pharmacology . . .
CCmax max afterafter
PO PO 1 hr 1 hr
SC, IM SC, IM 30 min 30 min
IV IV 6 min 6 min
Half-life at steady-state Half-life at steady-state
PO / PR / SC / IM / IV PO / PR / SC / IM / IV 3-4 hrs 3-4 hrs
CCmax max afterafter
PO PO 1 hr 1 hr
SC, IM SC, IM 30 min 30 min
IV IV 6 min 6 min
Half-life at steady-state Half-life at steady-state
PO / PR / SC / IM / IV PO / PR / SC / IM / IV 3-4 hrs 3-4 hrs
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. . . Opioid pharmacology. . . Opioid pharmacology
Steady state after 4–5 half-livesSteady state after 4–5 half-lives
Steady state after one day (24 hours)Steady state after one day (24 hours)
Duration of effect of ‘immediate-Duration of effect of ‘immediate-release’ formulations (except release’ formulations (except methadone)methadone)
3–5 hours PO / PR3–5 hours PO / PR
Shorter with parenteral bolusShorter with parenteral bolus
Steady state after 4–5 half-livesSteady state after 4–5 half-lives
Steady state after one day (24 hours)Steady state after one day (24 hours)
Duration of effect of ‘immediate-Duration of effect of ‘immediate-release’ formulations (except release’ formulations (except methadone)methadone)
3–5 hours PO / PR3–5 hours PO / PR
Shorter with parenteral bolusShorter with parenteral bolus
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Routine oral dosingImmediate-release preparationsRoutine oral dosingImmediate-release preparations
Codeine, hydrocodone, morphine, Codeine, hydrocodone, morphine, hydromorphone, oxycodonehydromorphone, oxycodone
Dose q 4 hDose q 4 h
Adjust dose dailyAdjust dose daily
Mild / moderate pain Mild / moderate pain 25–50%25–50%
Severe / uncontrolled pain Severe / uncontrolled pain 50–100%50–100%
Adjust more quickly for severe Adjust more quickly for severe uncontrolled painuncontrolled pain
Codeine, hydrocodone, morphine, Codeine, hydrocodone, morphine, hydromorphone, oxycodonehydromorphone, oxycodone
Dose q 4 hDose q 4 h
Adjust dose dailyAdjust dose daily
Mild / moderate pain Mild / moderate pain 25–50%25–50%
Severe / uncontrolled pain Severe / uncontrolled pain 50–100%50–100%
Adjust more quickly for severe Adjust more quickly for severe uncontrolled painuncontrolled pain
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. . . Routine oral dosingExtended-release preparations. . . Routine oral dosingExtended-release preparations
Improve compliance, adherenceImprove compliance, adherence
Dose q 8, 12 or 24 h (product Dose q 8, 12 or 24 h (product specific)specific)
Don’t crush or chew tabletsDon’t crush or chew tablets
May flush time-release granules down May flush time-release granules down feeding tubesfeeding tubes
Adjust dose q 2–4 days (once steady Adjust dose q 2–4 days (once steady state reached)state reached)
Improve compliance, adherenceImprove compliance, adherence
Dose q 8, 12 or 24 h (product Dose q 8, 12 or 24 h (product specific)specific)
Don’t crush or chew tabletsDon’t crush or chew tablets
May flush time-release granules down May flush time-release granules down feeding tubesfeeding tubes
Adjust dose q 2–4 days (once steady Adjust dose q 2–4 days (once steady state reached)state reached)
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Routine oral dosingLong half-life opioidsRoutine oral dosingLong half-life opioids
Dose interval for methadone is Dose interval for methadone is variable (q 6 h or q 8 h usually variable (q 6 h or q 8 h usually adequate)adequate)
Adjust methadone dose q 4–7 daysAdjust methadone dose q 4–7 days
Dose interval for methadone is Dose interval for methadone is variable (q 6 h or q 8 h usually variable (q 6 h or q 8 h usually adequate)adequate)
Adjust methadone dose q 4–7 daysAdjust methadone dose q 4–7 days
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Breakthrough dosingBreakthrough dosing
Use immediate-release opioidsUse immediate-release opioids
5–15% of 24 hr dose5–15% of 24 hr dose
offer after Coffer after Cmaxmax reached reached
PO / PR PO / PR q 1 h q 1 h
SC, IM SC, IM q 30min q 30min
IV IV q 10– q 10–15min15min
Do NOT use extended-release Do NOT use extended-release opioidsopioids
Use immediate-release opioidsUse immediate-release opioids
5–15% of 24 hr dose5–15% of 24 hr dose
offer after Coffer after Cmaxmax reached reached
PO / PR PO / PR q 1 h q 1 h
SC, IM SC, IM q 30min q 30min
IV IV q 10– q 10–15min15min
Do NOT use extended-release Do NOT use extended-release opioidsopioids
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Clearance concernsClearance concerns Conjugated by liverConjugated by liver
90–95% excreted in urine90–95% excreted in urine
Dehydration, renal failure, severe Dehydration, renal failure, severe hepatic failurehepatic failure
dosing interval, dosing interval, dosage size dosage size
If oliguria or anuriaIf oliguria or anuria
STOP routine dosing of STOP routine dosing of morphinemorphine
use ONLY PRNuse ONLY PRN
Conjugated by liverConjugated by liver
90–95% excreted in urine90–95% excreted in urine
Dehydration, renal failure, severe Dehydration, renal failure, severe hepatic failurehepatic failure
dosing interval, dosing interval, dosage size dosage size
If oliguria or anuriaIf oliguria or anuria
STOP routine dosing of STOP routine dosing of morphinemorphine
use ONLY PRNuse ONLY PRN
Mercadante S, Arcuri E. J Pain. 2004.
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Not recommended . . .Not recommended . . .
MeperidineMeperidine
Poor oral absorptionPoor oral absorption
Normeperidine is a toxic metaboliteNormeperidine is a toxic metabolite
Longer half-life (6 hrs), no Longer half-life (6 hrs), no analgesiaanalgesia
Psychotomimetic adverse Psychotomimetic adverse effects, myoclonus, seizureseffects, myoclonus, seizures
If dosing q 3 h for analgesia, If dosing q 3 h for analgesia, normeperidine builds upnormeperidine builds up
Accumulates with renal failureAccumulates with renal failure
MeperidineMeperidine
Poor oral absorptionPoor oral absorption
Normeperidine is a toxic metaboliteNormeperidine is a toxic metabolite
Longer half-life (6 hrs), no Longer half-life (6 hrs), no analgesiaanalgesia
Psychotomimetic adverse Psychotomimetic adverse effects, myoclonus, seizureseffects, myoclonus, seizures
If dosing q 3 h for analgesia, If dosing q 3 h for analgesia, normeperidine builds upnormeperidine builds up
Accumulates with renal failureAccumulates with renal failure
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. . . Not recommended . . .. . . Not recommended . . .
PropoxyphenePropoxyphene
No better than placeboNo better than placebo
Low efficacy at commercially Low efficacy at commercially available dosesavailable doses
Toxic metabolite at high dosesToxic metabolite at high doses
PropoxyphenePropoxyphene
No better than placeboNo better than placebo
Low efficacy at commercially Low efficacy at commercially available dosesavailable doses
Toxic metabolite at high dosesToxic metabolite at high doses
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. . . Not recommended. . . Not recommended
Mixed agonist-antagonistsMixed agonist-antagonists
Pentazocine, butorphanol, nalbuphine, Pentazocine, butorphanol, nalbuphine, dezocinedezocine
Compete with agonists Compete with agonists withdrawalwithdrawal
Analgesic ceiling effectAnalgesic ceiling effect
High risk of psychotomimetic High risk of psychotomimetic adverse effects with adverse effects with pentazocine, butorphanolpentazocine, butorphanol
Mixed agonist-antagonistsMixed agonist-antagonists
Pentazocine, butorphanol, nalbuphine, Pentazocine, butorphanol, nalbuphine, dezocinedezocine
Compete with agonists Compete with agonists withdrawalwithdrawal
Analgesic ceiling effectAnalgesic ceiling effect
High risk of psychotomimetic High risk of psychotomimetic adverse effects with adverse effects with pentazocine, butorphanolpentazocine, butorphanol
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Addiction . . .Addiction . . .
Psychological dependencePsychological dependence
Compulsive useCompulsive use
Loss of control over drugsLoss of control over drugs
Loss of interest in pleasurable Loss of interest in pleasurable activitiesactivities
Psychological dependencePsychological dependence
Compulsive useCompulsive use
Loss of control over drugsLoss of control over drugs
Loss of interest in pleasurable Loss of interest in pleasurable activitiesactivities
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. . . Addiction. . . Addiction
Continued use of drugs in spite of Continued use of drugs in spite of harmharm
A rare outcome of pain management A rare outcome of pain management
Particularly, if no history of substance Particularly, if no history of substance abuseabuse
Continued use of drugs in spite of Continued use of drugs in spite of harmharm
A rare outcome of pain management A rare outcome of pain management
Particularly, if no history of substance Particularly, if no history of substance abuseabuse
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. . . Addiction. . . Addiction
ConsiderConsider
Substance use (true addiction)Substance use (true addiction)
Pseudo-addiction (under-treatment of Pseudo-addiction (under-treatment of pain)pain)
Behavioral/family/psychological Behavioral/family/psychological disorderdisorder
Drug diversionDrug diversion
ConsiderConsider
Substance use (true addiction)Substance use (true addiction)
Pseudo-addiction (under-treatment of Pseudo-addiction (under-treatment of pain)pain)
Behavioral/family/psychological Behavioral/family/psychological disorderdisorder
Drug diversionDrug diversion
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ToleranceTolerance
Reduced effectiveness to a given Reduced effectiveness to a given dose over timedose over time
Not clinically significant with chronic Not clinically significant with chronic dosingdosing
If dose is increasing, suspect If dose is increasing, suspect disease progressiondisease progression
Reduced effectiveness to a given Reduced effectiveness to a given dose over timedose over time
Not clinically significant with chronic Not clinically significant with chronic dosingdosing
If dose is increasing, suspect If dose is increasing, suspect disease progressiondisease progression
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Physical dependencePhysical dependence
A process of neuro adaptationA process of neuro adaptation
Abrupt withdrawal may Abrupt withdrawal may abstinence abstinence syndromesyndrome
If dose reduction required, reduce by If dose reduction required, reduce by 50% q 2–3 days50% q 2–3 days
Avoid antagonistsAvoid antagonists
A process of neuro adaptationA process of neuro adaptation
Abrupt withdrawal may Abrupt withdrawal may abstinence abstinence syndromesyndrome
If dose reduction required, reduce by If dose reduction required, reduce by 50% q 2–3 days50% q 2–3 days
Avoid antagonistsAvoid antagonists
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Substance usersSubstance users
Can have pain tooCan have pain too
Treat with compassion Treat with compassion
Protocols, contractingProtocols, contracting
Consultation with pain or addiction Consultation with pain or addiction specialistsspecialists
Can have pain tooCan have pain too
Treat with compassion Treat with compassion
Protocols, contractingProtocols, contracting
Consultation with pain or addiction Consultation with pain or addiction specialistsspecialists
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Pain poorly-responsiveto opioidsPain poorly-responsiveto opioids If dose escalation If dose escalation adverse effects adverse effects
More sophisticated therapy to More sophisticated therapy to counteract adverse effectcounteract adverse effect
AlternativeAlternative
Route of administrationRoute of administration
Opioid (‘opioid rotation’)Opioid (‘opioid rotation’)
CoanalgesicCoanalgesic
Use a non-pharmacological approachUse a non-pharmacological approach
If dose escalation If dose escalation adverse effects adverse effects
More sophisticated therapy to More sophisticated therapy to counteract adverse effectcounteract adverse effect
AlternativeAlternative
Route of administrationRoute of administration
Opioid (‘opioid rotation’)Opioid (‘opioid rotation’)
CoanalgesicCoanalgesic
Use a non-pharmacological approachUse a non-pharmacological approach
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Ongoing assessmentOngoing assessment
Increase analgesics until pain Increase analgesics until pain relieved or adverse effects relieved or adverse effects unacceptableunacceptable
Be prepared for sudden changes in Be prepared for sudden changes in painpain
Driving is safe ifDriving is safe if
Pain controlled, dose stable, no adverse Pain controlled, dose stable, no adverse effectseffects
Increase analgesics until pain Increase analgesics until pain relieved or adverse effects relieved or adverse effects unacceptableunacceptable
Be prepared for sudden changes in Be prepared for sudden changes in painpain
Driving is safe ifDriving is safe if
Pain controlled, dose stable, no adverse Pain controlled, dose stable, no adverse effectseffects
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Alternative routesof administrationAlternative routesof administration Enteral feeding tubesEnteral feeding tubes
TransmucosalTransmucosal
RectalRectal
Transdermal Transdermal
ParenteralParenteral
IntraspinalIntraspinal
Enteral feeding tubesEnteral feeding tubes
TransmucosalTransmucosal
RectalRectal
Transdermal Transdermal
ParenteralParenteral
IntraspinalIntraspinal
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Transdermal patchTransdermal patch
FentanylFentanyl
Peak effect after application Peak effect after application 24 hrs 24 hrs
Patch lasts 48–72 hrsPatch lasts 48–72 hrs
Ensure adherence to skinEnsure adherence to skin
FentanylFentanyl
Peak effect after application Peak effect after application 24 hrs 24 hrs
Patch lasts 48–72 hrsPatch lasts 48–72 hrs
Ensure adherence to skinEnsure adherence to skin
Gourlay GK, et al. Pain. 1989.
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ParenteralParenteral
SC, IV, IMSC, IV, IM
Bolus dosing q 3–4 hBolus dosing q 3–4 h
Continuous infusionContinuous infusion
Easier to administerEasier to administer
More even pain controlMore even pain control
SC, IV, IMSC, IV, IM
Bolus dosing q 3–4 hBolus dosing q 3–4 h
Continuous infusionContinuous infusion
Easier to administerEasier to administer
More even pain controlMore even pain control
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IntraspinalIntraspinal
EpiduralEpidural
IntrathecalIntrathecal
Morphine, hydromorphone, fentanylMorphine, hydromorphone, fentanyl
ConsultationConsultation
EpiduralEpidural
IntrathecalIntrathecal
Morphine, hydromorphone, fentanylMorphine, hydromorphone, fentanyl
ConsultationConsultation
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Bolus effectBolus effect
Swings in plasma concentrationSwings in plasma concentration
Drowsiness ½ –1 hr post ingestionDrowsiness ½ –1 hr post ingestion
Pain before next dose duePain before next dose due
Must move to Must move to
Extended-release preparationExtended-release preparation
Continuous SC, IV infusionContinuous SC, IV infusion
Swings in plasma concentrationSwings in plasma concentration
Drowsiness ½ –1 hr post ingestionDrowsiness ½ –1 hr post ingestion
Pain before next dose duePain before next dose due
Must move to Must move to
Extended-release preparationExtended-release preparation
Continuous SC, IV infusionContinuous SC, IV infusion
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Changing routesof administrationChanging routesof administration Equianalgesic tableEquianalgesic table
Guide to initial dose selectionGuide to initial dose selection
Significant first-pass metabolism of Significant first-pass metabolism of PO / PR dosesPO / PR doses
Codeine, hydromorphone, morphineCodeine, hydromorphone, morphine
PO / PRPO / PRtoto SC, IV, IMSC, IV, IM
2–32–3 11
Equianalgesic tableEquianalgesic table
Guide to initial dose selectionGuide to initial dose selection
Significant first-pass metabolism of Significant first-pass metabolism of PO / PR dosesPO / PR doses
Codeine, hydromorphone, morphineCodeine, hydromorphone, morphine
PO / PRPO / PRtoto SC, IV, IMSC, IV, IM
2–32–3 11
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Equianalgesic dosesof opioid analgesicsEquianalgesic dosesof opioid analgesics
PO / PR PO / PR (mg)(mg) AnalgesicAnalgesic SC / IV / IM SC / IV / IM (mg)(mg)
100100 CodeineCodeine 6060
1515 HydrocodoneHydrocodone --
44 HydromorphoneHydromorphone 1.51.5
1515 MorphineMorphine 55
1010 OxycodoneOxycodone --
PO / PR PO / PR (mg)(mg) AnalgesicAnalgesic SC / IV / IM SC / IV / IM (mg)(mg)
100100 CodeineCodeine 6060
1515 HydrocodoneHydrocodone --
44 HydromorphoneHydromorphone 1.51.5
1515 MorphineMorphine 55
1010 OxycodoneOxycodone --
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Changing opioids . . .Changing opioids . . .
Equianalgesic tableEquianalgesic table
Transdermal fentanylTransdermal fentanyl
25 25 g patch g patch 45–135 (likely 50–60) mg 45–135 (likely 50–60) mg morphine / 24 hrs morphine / 24 hrs
Equianalgesic tableEquianalgesic table
Transdermal fentanylTransdermal fentanyl
25 25 g patch g patch 45–135 (likely 50–60) mg 45–135 (likely 50–60) mg morphine / 24 hrs morphine / 24 hrs
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. . . Changing opioids. . . Changing opioids
Cross-toleranceCross-tolerance
Start with 50–75% of published Start with 50–75% of published equianalgesic doseequianalgesic dose
More if pain, less if adverse More if pain, less if adverse effectseffects
MethadoneMethadone
Start with 10–25% of published Start with 10–25% of published equianalgesic doseequianalgesic dose
Cross-toleranceCross-tolerance
Start with 50–75% of published Start with 50–75% of published equianalgesic doseequianalgesic dose
More if pain, less if adverse More if pain, less if adverse effectseffects
MethadoneMethadone
Start with 10–25% of published Start with 10–25% of published equianalgesic doseequianalgesic dose
Ripamonti C, Zecca E, Bruera E. Pain. 1997.
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Adjuvant analgesics Adjuvant analgesics
Medications that supplement primary Medications that supplement primary analgesicsanalgesics
May themselves be primary analgesicsMay themselves be primary analgesics
Use at any step of WHO ladderUse at any step of WHO ladder
Medications that supplement primary Medications that supplement primary analgesicsanalgesics
May themselves be primary analgesicsMay themselves be primary analgesics
Use at any step of WHO ladderUse at any step of WHO ladder
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Gabapentin Gabapentin
AnticonvulsantAnticonvulsant
100 mg PO daily to tid, titrate100 mg PO daily to tid, titrate
Increase dose q 1–3 dIncrease dose q 1–3 d
Usual effective dose 900–1800 mg / day; Usual effective dose 900–1800 mg / day; max may be > 3600 mg / daymax may be > 3600 mg / day
Minimal adverse effectsMinimal adverse effects
Drowsiness, tolerance develops Drowsiness, tolerance develops within dayswithin days
AnticonvulsantAnticonvulsant
100 mg PO daily to tid, titrate100 mg PO daily to tid, titrate
Increase dose q 1–3 dIncrease dose q 1–3 d
Usual effective dose 900–1800 mg / day; Usual effective dose 900–1800 mg / day; max may be > 3600 mg / daymax may be > 3600 mg / day
Minimal adverse effectsMinimal adverse effects
Drowsiness, tolerance develops Drowsiness, tolerance develops within dayswithin days
Backonja, et al. JAMA. 1998.
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Other anticonvulsantsOther anticonvulsants CarbamazepineCarbamazepine
100 mg PO bid, titrate100 mg PO bid, titrate
Valproic acidValproic acid
250 mg PO q hs, titrate250 mg PO q hs, titrate
Monitor plasma levels for risk of toxicityMonitor plasma levels for risk of toxicity
ClonazepamClonazepam
LamotrigineLamotrigine
CarbamazepineCarbamazepine
100 mg PO bid, titrate100 mg PO bid, titrate
Valproic acidValproic acid
250 mg PO q hs, titrate250 mg PO q hs, titrate
Monitor plasma levels for risk of toxicityMonitor plasma levels for risk of toxicity
ClonazepamClonazepam
LamotrigineLamotrigine
McQuay, et al. BMJ. 1995.Eisenberg E, et al. Neurology. 2001.
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Tricyclic antidepressantsTricyclic antidepressants
AmitriptylineAmitriptyline
Most extensively studiedMost extensively studied
10–25 mg PO nightly, titrate 10–25 mg PO nightly, titrate (escalate q 4–7 d)(escalate q 4–7 d)
Analgesia in days to weeksAnalgesia in days to weeks
AmitriptylineAmitriptyline
Most extensively studiedMost extensively studied
10–25 mg PO nightly, titrate 10–25 mg PO nightly, titrate (escalate q 4–7 d)(escalate q 4–7 d)
Analgesia in days to weeksAnalgesia in days to weeks
Max, et al .N Engl J Med. 1992.
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. . . Tricyclic antidepressants . . .. . . Tricyclic antidepressants . . .
AmitriptylineAmitriptyline
Monitor plasma drug levels Monitor plasma drug levels > 100 mg / 24h for risk of toxicity> 100 mg / 24h for risk of toxicity
Anticholinergic adverse effects Anticholinergic adverse effects prominent, cardiac toxicityprominent, cardiac toxicity
Sedating limited usefulness in frail, Sedating limited usefulness in frail, elderlyelderly
AmitriptylineAmitriptyline
Monitor plasma drug levels Monitor plasma drug levels > 100 mg / 24h for risk of toxicity> 100 mg / 24h for risk of toxicity
Anticholinergic adverse effects Anticholinergic adverse effects prominent, cardiac toxicityprominent, cardiac toxicity
Sedating limited usefulness in frail, Sedating limited usefulness in frail, elderlyelderly
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. . . Tricyclic antidepressants. . . Tricyclic antidepressants
DesipramineDesipramine
Minimal anticholinergic or sedating Minimal anticholinergic or sedating adverse effectsadverse effects
10–25 mg PO q hs, titrate10–25 mg PO q hs, titrate
Tricyclic of choice in seriously illTricyclic of choice in seriously ill
Nortriptyline is an alternativeNortriptyline is an alternative
DesipramineDesipramine
Minimal anticholinergic or sedating Minimal anticholinergic or sedating adverse effectsadverse effects
10–25 mg PO q hs, titrate10–25 mg PO q hs, titrate
Tricyclic of choice in seriously illTricyclic of choice in seriously ill
Nortriptyline is an alternativeNortriptyline is an alternative
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Corticosteroids . . .Corticosteroids . . .
Many usesMany uses
DexamethasoneDexamethasone
Long half-life (>36 hrs), dose once / dayLong half-life (>36 hrs), dose once / day
Minimal mineralocorticoid effectMinimal mineralocorticoid effect
Doses of 2–20 + mg / dayDoses of 2–20 + mg / day
Many usesMany uses
DexamethasoneDexamethasone
Long half-life (>36 hrs), dose once / dayLong half-life (>36 hrs), dose once / day
Minimal mineralocorticoid effectMinimal mineralocorticoid effect
Doses of 2–20 + mg / dayDoses of 2–20 + mg / day
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. . . Corticosteroids. . . Corticosteroids
Adverse effectsAdverse effects
Steroid psychosisSteroid psychosis
Proximal myopathyProximal myopathy
Other long-term adverse effectsOther long-term adverse effects
Adverse effectsAdverse effects
Steroid psychosisSteroid psychosis
Proximal myopathyProximal myopathy
Other long-term adverse effectsOther long-term adverse effects
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Bone pain . . .Bone pain . . .
Constant, worse with movementConstant, worse with movement
Metastases, compression or Metastases, compression or pathological fracturespathological fractures
Prostaglandins from inflammation, Prostaglandins from inflammation, metastasesmetastases
Rule out cord compressionRule out cord compression
Constant, worse with movementConstant, worse with movement
Metastases, compression or Metastases, compression or pathological fracturespathological fractures
Prostaglandins from inflammation, Prostaglandins from inflammation, metastasesmetastases
Rule out cord compressionRule out cord compression
Blum, et al. Oncology. 2003.
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. . . Bone pain . . .. . . Bone pain . . .
ManagementManagement
OpioidsOpioids
NSAIDsNSAIDs
CorticosteroidsCorticosteroids
BisphosphonatesBisphosphonates
CalcitoninCalcitonin
ManagementManagement
OpioidsOpioids
NSAIDsNSAIDs
CorticosteroidsCorticosteroids
BisphosphonatesBisphosphonates
CalcitoninCalcitonin
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. . . Bone pain. . . Bone pain
ManagementManagement
RadiopharmaceuticalsRadiopharmaceuticals
External beam radiationExternal beam radiation
Orthopedic interventionOrthopedic intervention
External bracingExternal bracing
ConsultationConsultation
ManagementManagement
RadiopharmaceuticalsRadiopharmaceuticals
External beam radiationExternal beam radiation
Orthopedic interventionOrthopedic intervention
External bracingExternal bracing
ConsultationConsultation
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Pain from bowel obstruction . . .Pain from bowel obstruction . . . ConstipationConstipation
External compressionExternal compression
Bowel wall stretch, inflammationBowel wall stretch, inflammation
Associated symptomsAssociated symptoms
Definitive interventionDefinitive intervention
Relief of constipationRelief of constipation
Surgical removal or bypassSurgical removal or bypass
ConstipationConstipation
External compressionExternal compression
Bowel wall stretch, inflammationBowel wall stretch, inflammation
Associated symptomsAssociated symptoms
Definitive interventionDefinitive intervention
Relief of constipationRelief of constipation
Surgical removal or bypassSurgical removal or bypass
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. . . Pain from bowel obstruction. . . Pain from bowel obstruction ManagementManagement
OpioidsOpioids
CorticosteroidsCorticosteroids
NSAIDsNSAIDs
Anticholinergic medications Anticholinergic medications eg, scopolamineeg, scopolamine
OctreotideOctreotide
ManagementManagement
OpioidsOpioids
CorticosteroidsCorticosteroids
NSAIDsNSAIDs
Anticholinergic medications Anticholinergic medications eg, scopolamineeg, scopolamine
OctreotideOctreotide
Muir JC, von Gunten CF. Clin Geriatr Med. 2000.
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Opioid adverse effectsOpioid adverse effects
CommonCommon UncommonUncommon
ConstipationConstipation Bad dreams / Bad dreams / hallucinationshallucinations
Dry mouthDry mouth Dysphoria / deliriumDysphoria / delirium
Nausea / vomitingNausea / vomiting Myoclonus / seizuresMyoclonus / seizures
SedationSedation Pruritus / urticariaPruritus / urticaria
SweatsSweats Respiratory depressionRespiratory depression
Urinary retentionUrinary retention
CommonCommon UncommonUncommon
ConstipationConstipation Bad dreams / Bad dreams / hallucinationshallucinations
Dry mouthDry mouth Dysphoria / deliriumDysphoria / delirium
Nausea / vomitingNausea / vomiting Myoclonus / seizuresMyoclonus / seizures
SedationSedation Pruritus / urticariaPruritus / urticaria
SweatsSweats Respiratory depressionRespiratory depression
Urinary retentionUrinary retention
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Opioid allergyOpioid allergy
Nausea / vomiting, constipation, Nausea / vomiting, constipation, drowsiness, confusiondrowsiness, confusion
Adverse effects, not allergic reactionsAdverse effects, not allergic reactions
Anaphylactic reactions are the only Anaphylactic reactions are the only true allergiestrue allergies
BronchospasmBronchospasm
Urticaria, bronchospasm can be Urticaria, bronchospasm can be allergies; need careful assessmentallergies; need careful assessment
Nausea / vomiting, constipation, Nausea / vomiting, constipation, drowsiness, confusiondrowsiness, confusion
Adverse effects, not allergic reactionsAdverse effects, not allergic reactions
Anaphylactic reactions are the only Anaphylactic reactions are the only true allergiestrue allergies
BronchospasmBronchospasm
Urticaria, bronchospasm can be Urticaria, bronchospasm can be allergies; need careful assessmentallergies; need careful assessment
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Urticaria, pruritusUrticaria, pruritus
Mast cell destabilization by Mast cell destabilization by morphine, hydromorphonemorphine, hydromorphone
Treat with routine long-acting, non-Treat with routine long-acting, non-sedating antihistaminessedating antihistamines
Fexofenadine 60 mg PO bid, or higherFexofenadine 60 mg PO bid, or higher
or try diphenhydramine, loratadine or or try diphenhydramine, loratadine or doxepindoxepin
Mast cell destabilization by Mast cell destabilization by morphine, hydromorphonemorphine, hydromorphone
Treat with routine long-acting, non-Treat with routine long-acting, non-sedating antihistaminessedating antihistamines
Fexofenadine 60 mg PO bid, or higherFexofenadine 60 mg PO bid, or higher
or try diphenhydramine, loratadine or or try diphenhydramine, loratadine or doxepindoxepin
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ConstipationConstipation
Common to all opioidsCommon to all opioids
Opioid effects on CNS, spinal cord, Opioid effects on CNS, spinal cord, myenteric plexus of gutmyenteric plexus of gut
Easier to prevent than treatEasier to prevent than treat
Common to all opioidsCommon to all opioids
Opioid effects on CNS, spinal cord, Opioid effects on CNS, spinal cord, myenteric plexus of gutmyenteric plexus of gut
Easier to prevent than treatEasier to prevent than treat
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. . . Constipation . . .. . . Constipation . . .
Diet usually insufficientDiet usually insufficient
Bulk forming agents not Bulk forming agents not recommendedrecommended
Stimulant laxativeStimulant laxative
Senna, bisacodyl, glycerine, Senna, bisacodyl, glycerine, casanthranol, etc.casanthranol, etc.
Combine with a stool softenerCombine with a stool softener
Senna + docusate sodiumSenna + docusate sodium
Diet usually insufficientDiet usually insufficient
Bulk forming agents not Bulk forming agents not recommendedrecommended
Stimulant laxativeStimulant laxative
Senna, bisacodyl, glycerine, Senna, bisacodyl, glycerine, casanthranol, etc.casanthranol, etc.
Combine with a stool softenerCombine with a stool softener
Senna + docusate sodiumSenna + docusate sodium
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. . . Constipation. . . Constipation
Prokinetic agentProkinetic agent
Metoclopramide, cisaprideMetoclopramide, cisapride
Osmotic laxativeOsmotic laxative
MOM, lactulose, sorbitolMOM, lactulose, sorbitol
Other measuresOther measures
Prokinetic agentProkinetic agent
Metoclopramide, cisaprideMetoclopramide, cisapride
Osmotic laxativeOsmotic laxative
MOM, lactulose, sorbitolMOM, lactulose, sorbitol
Other measuresOther measures
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Nausea / vomiting . . .Nausea / vomiting . . .
Onset with start of opioidsOnset with start of opioids
Tolerance develops within daysTolerance develops within days
Prevent or treat with dopamine-Prevent or treat with dopamine-blocking antiemeticsblocking antiemetics
Prochlorperazine 10 mg q 6 hProchlorperazine 10 mg q 6 h
Haloperidol 1 mg 6 hHaloperidol 1 mg 6 h
Metoclopramide 10 mg q 6 hMetoclopramide 10 mg q 6 h
Onset with start of opioidsOnset with start of opioids
Tolerance develops within daysTolerance develops within days
Prevent or treat with dopamine-Prevent or treat with dopamine-blocking antiemeticsblocking antiemetics
Prochlorperazine 10 mg q 6 hProchlorperazine 10 mg q 6 h
Haloperidol 1 mg 6 hHaloperidol 1 mg 6 h
Metoclopramide 10 mg q 6 hMetoclopramide 10 mg q 6 h
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. . . Nausea / vomiting. . . Nausea / vomiting
Other antiemetics may also be Other antiemetics may also be effectiveeffective
Alternative opioid if refractoryAlternative opioid if refractory
Other antiemetics may also be Other antiemetics may also be effectiveeffective
Alternative opioid if refractoryAlternative opioid if refractory
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Sedation . . .Sedation . . .
Onset with start of opioidsOnset with start of opioids
Distinguish from exhaustion due to painDistinguish from exhaustion due to pain
Tolerance develops within daysTolerance develops within days
Complex in advanced diseaseComplex in advanced disease
Onset with start of opioidsOnset with start of opioids
Distinguish from exhaustion due to painDistinguish from exhaustion due to pain
Tolerance develops within daysTolerance develops within days
Complex in advanced diseaseComplex in advanced disease
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. . . Sedation. . . Sedation
If persistent, alternative opioid or If persistent, alternative opioid or route of administrationroute of administration
Psychostimulants may be usefulPsychostimulants may be useful
Methylphenidate 5 mg q am and q noon, Methylphenidate 5 mg q am and q noon, titratetitrate
If persistent, alternative opioid or If persistent, alternative opioid or route of administrationroute of administration
Psychostimulants may be usefulPsychostimulants may be useful
Methylphenidate 5 mg q am and q noon, Methylphenidate 5 mg q am and q noon, titratetitrate
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Delirium . . .Delirium . . .
PresentationPresentation
Confusion, bad dreams, hallucinationsConfusion, bad dreams, hallucinations
Restlessness, agitationRestlessness, agitation
Myoclonic jerks, seizuresMyoclonic jerks, seizures
Depressed level of consciousnessDepressed level of consciousness
Respiratory depressionRespiratory depression
PresentationPresentation
Confusion, bad dreams, hallucinationsConfusion, bad dreams, hallucinations
Restlessness, agitationRestlessness, agitation
Myoclonic jerks, seizuresMyoclonic jerks, seizures
Depressed level of consciousnessDepressed level of consciousness
Respiratory depressionRespiratory depression
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. . . Delirium. . . Delirium
Rare, unless multiple factors Rare, unless multiple factors contributing, if contributing, if
Opioid dosing guidelines followedOpioid dosing guidelines followed
Renal clearance normalRenal clearance normal
Rare, unless multiple factors Rare, unless multiple factors contributing, if contributing, if
Opioid dosing guidelines followedOpioid dosing guidelines followed
Renal clearance normalRenal clearance normal
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Respiratory depression . . .Respiratory depression . . . Opioid effects differ for patients Opioid effects differ for patients
treated for paintreated for pain
Pain is a potent stimulus to breathePain is a potent stimulus to breathe
Loss of consciousness precedes Loss of consciousness precedes respiratory depressionrespiratory depression
Pharmacological tolerance rapidPharmacological tolerance rapid
Opioid effects differ for patients Opioid effects differ for patients treated for paintreated for pain
Pain is a potent stimulus to breathePain is a potent stimulus to breathe
Loss of consciousness precedes Loss of consciousness precedes respiratory depressionrespiratory depression
Pharmacological tolerance rapidPharmacological tolerance rapid
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. . . Respiratory depression. . . Respiratory depression ManagementManagement
Identify, treat contributing causesIdentify, treat contributing causes
Reduce opioid doseReduce opioid dose
ObserveObserve
If unstable vital signsIf unstable vital signs
Naloxone 0.1-0.2 mg IV q 1-2 minNaloxone 0.1-0.2 mg IV q 1-2 min
ManagementManagement
Identify, treat contributing causesIdentify, treat contributing causes
Reduce opioid doseReduce opioid dose
ObserveObserve
If unstable vital signsIf unstable vital signs
Naloxone 0.1-0.2 mg IV q 1-2 minNaloxone 0.1-0.2 mg IV q 1-2 min
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Non-pharmacological pain management . . .Non-pharmacological pain management . . . NeurostimulationNeurostimulation
TENS, acupunctureTENS, acupuncture
AnesthesiologicalAnesthesiologicalNerve blockNerve block
SurgicalSurgicalCordotomyCordotomy
Physical therapyPhysical therapyExercise, heat, coldExercise, heat, cold
NeurostimulationNeurostimulationTENS, acupunctureTENS, acupuncture
AnesthesiologicalAnesthesiologicalNerve blockNerve block
SurgicalSurgicalCordotomyCordotomy
Physical therapyPhysical therapyExercise, heat, coldExercise, heat, cold
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. . . Non-pharmacological pain management. . . Non-pharmacological pain management Psychological approachesPsychological approaches
Cognitive therapiesCognitive therapies(relaxation, imagery, hypnosis)(relaxation, imagery, hypnosis)
BiofeedbackBiofeedback
Behavior therapy, psychotherapy Behavior therapy, psychotherapy
Complementary therapiesComplementary therapies
MassageMassage
Art, music, aroma therapyArt, music, aroma therapy
Psychological approachesPsychological approaches
Cognitive therapiesCognitive therapies(relaxation, imagery, hypnosis)(relaxation, imagery, hypnosis)
BiofeedbackBiofeedback
Behavior therapy, psychotherapy Behavior therapy, psychotherapy
Complementary therapiesComplementary therapies
MassageMassage
Art, music, aroma therapyArt, music, aroma therapy
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Barriers . . .Barriers . . .
Not importantNot important
Poor assessmentPoor assessment
Lack of knowledgeLack of knowledge
Fear ofFear of
AddictionAddiction
ToleranceTolerance
Adverse effectsAdverse effects
Not importantNot important
Poor assessmentPoor assessment
Lack of knowledgeLack of knowledge
Fear ofFear of
AddictionAddiction
ToleranceTolerance
Adverse effectsAdverse effects
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. . . Barriers. . . Barriers
Regulatory oversightRegulatory oversight
Patient’s unwilling to report painPatient’s unwilling to report pain
Patients unwilling to take medicinePatients unwilling to take medicine
Regulatory oversightRegulatory oversight
Patient’s unwilling to report painPatient’s unwilling to report pain
Patients unwilling to take medicinePatients unwilling to take medicine
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EEPPEECC
OO
EEPPEECC
OO
SummarySummary
Pain management is an Pain management is an essential component of essential component of
comprehensive cancer carecomprehensive cancer care
Pain management is an Pain management is an essential component of essential component of
comprehensive cancer carecomprehensive cancer care