what analgesics?
DESCRIPTION
What Analgesics?. Paracetamol – Aspirin Nefopam NSAIDS Opioids Topical – capsaicin, rubifacients , nsaids , Local anaesthetics. Add on’s. Diazepam, methocarbamol. Amitriptylline TENS machine Stretching, massage, physio Osteopathy, Acupuncture Antidepressants. 3. - PowerPoint PPT PresentationTRANSCRIPT
• Paracetamol – • Aspirin• Nefopam• NSAIDS• Opioids
• Topical – capsaicin, rubifacients, nsaids, Local anaesthetics
What Analgesics?
• Diazepam, methocarbamol.• Amitriptylline• TENS machine• Stretching, massage, physio Osteopathy,
Acupuncture • Antidepressants
Add on’s
WHO's three step ladder to use of analgesic drugs www.who.int/cancer/palliative/painladder
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OpioidsWeak Equivalent dose
of MORPHINE
Codeine 30-60mg qdsMAX 240mg/day 40mg / day
Dihydrocodeine 30-60mg qdsMAX 240mg/day 50mg / day
More s/e euphoria etc?
Tramadol 50-100mg qds or s/r formulation
40 – 80mg / day Less predictable
Buprenorphine 5mcg t/d70mcg t/d
10mg / day120mg / day
7 day patch
OpioidsStrong Equivalent dose of
MORPHINE
OXYCODONE Oxycodone 20mg40mg / day
Less s/e resp depression etc.
Fentanyl Patch 25mcg patch100mcg patch
60-100mg / day360mg / day
5 day patch
Morphine
Equivalent strengths of transdermal opioids
(i.e. Don’t mix up your fentanyl with your butrans!)
• constipation, nausea, somnolence, itching, dizziness, vomiting
• Tolerance to SE usually occurs within few days,• Constipation & itching tend to persist• Manage with antiemetics (cyclizine), aperients
(movicol), antihistamines• Respiratory depression only likely with major changes
in dose, formulation or route. • Accidental overdose is most likely cause• Caution if >1 sedative drug or other disorders of
respiratory control ( eg OSA)
S/e of opiates
• Endocrine impairment in both men and women• Hypothalamic-pituitary pituitary-adrenal/
gonadal axis suppression leading to amenorrhoea, infertility, reduced libido, infertility, depression, erectile dysfunction.
• Immunological effects- in animals, effects on antimicrobial response and tumour surveillance.
• Opioid induced hyperalgesia - reduce dose, change preparation
• Pregnancy & neonatal effects
Long-term adverse effects
• Large differences between individuals in susceptibility to, and severity of, withdrawal syndrome
• Symptoms last up to 72hrs following reduction/withdrawal.
• Incremental dose reductions 10% -25% depending on patient response and bear in mind half life of preparation
Stopping strong opioid medication
• Useful analgesia in the short and medium term.
No data to support longer term use.• Useful in neuropathic pain too.
• Complete relief of pain is rarely achieved. The goal should be to reduce pain sufficiently to facilitate engagement with rehabilitation and the restoration of useful function. Use as part of a wider management plan to reduce disability and improve QOL.
Recommendations 1:
• 80% of patients taking opioids experience at least one adverse effect. Discuss before treatment! DO NOT USE in pregnancy / children and use with caution in Elderly.
• Resp. depression commoner if elderly/coprescription / comorbidity e.g. OSA.
• Withdrawl symptoms – yawning, sweating abdo cramps common with abrupt withdrawl even short courses of tramadol.
Recommendations 2
• Educate re long term effects of opioids, particularly in relation to endocrine and immune function. Warn re Steroid induced Hyperalgesia.
• Do not use as first line• Consider carefully the decision to start long
term therapy and make arrangements for long-term monitoring and follow-up.
• Use modified release opioids for long term use
Recommendations 3
• Avoid driving at the start of opioid therapy and following major dose changes. Patients responsibility to advise the DVLA that they are taking opioid medication.
• Addiction is characterised by impaired control over use, craving and continued use despite harm.
Recommendations 4