pain management part 2 use of adjuvants john mulder, md, faahpm vice president of medical services...
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Pain Management Part 2Use of Adjuvants
John Mulder, MD, FAAHPMVice 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
• 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
Alternative/Adjuvant Medications
• Steroids - high dose, short term/low-dose, long term
• Antihistamines (Benedryl, Vistaril)
• Alpha-2-adrenergic stimulants (Clonidine)
• Cannabanoids
Alternative/Adjuvant Medications
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. ...
• OMM
• Acupuncture
• Acupressure
• Massage Therapy
• Music Therapy
• Hypnosis
• Relaxation
Non-pharmacologic Interventions
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