Items in AFP with MESH term: Analgesics, Opioid
ABSTRACT: Effective pain management in the terminally ill patient requires an understanding of pain control strategies. Ongoing assessment of pain is crucial and can be accomplished using various forms and scales. It is also important to determine if the pain is nociceptive (somatic or visceral pain) or neuropathic (continuous dysesthesias or chronic lancinating or paroxysmal pain). Nociceptive pain can usually be controlled with nonsteroidal antiinflammatory drugs or corticosteroids, whereas neuropathic pain responds to tricyclic antidepressants or anticonvulsants. Relief of breakthrough pain requires the administration of an immediate-release analgesic medication. If a significant amount of medication for breakthrough pain is already being given, the baseline dose of sustained-release analgesic medication should be increased. If pain does not respond to one analgesic medication, physicians should use an equianalgesic dose chart when changing the medication or route of administration. Opioid rotation can be used if pain can no longer be controlled on a specific regimen. The impact of unresolved psychosocial or spiritual issues on pain management may need to be addressed.
ABSTRACT: In addition to pain, patients who are approaching the end of life commonly have other symptoms. Unless contraindicated, prophylaxis with a gastrointestinal motility stimulant laxative and a stool softener is appropriate in terminally ill patients who are being given opioids. Patients with low performance status are not candidates for surgical treatment of bowel obstruction. Cramping abdominal pain associated with mechanical bowel obstruction often can be managed with morphine (titrating the dosage for pain) and octreotide. Delirium is common at the end of life and is frequently caused by a combination of medications, dehydration, infections or hypoxia. Haloperidol is the pharmaceutical agent of choice for the management of delirium. Dyspnea, the subjective sensation of uncomfortable breathing, is often treated by titration of an opioid to relieve the symptom; a benzodiazepine is used when anxiety is a component of the breathlessness.
Methadone Treatment for Pain States - Article
ABSTRACT: Methadone is a synthetic opioid with potent analgesic effects. Although it is associated commonly with the treatment of opioid addiction, it may be prescribed by licensed family physicians for analgesia. Methadone's unique pharmacokinetics and pharmacodynamics make it a valuable option in the management of cancer pain and other chronic pain, including neuropathic pain states. It may be an appropriate replacement for opioids when side effects have limited further dosage escalation. Metabolism of and response to methadone varies with each patient. Transition to methadone and dosage titration should be completed slowly and with frequent monitoring. Conversion should be based on the current daily oral morphine equivalent dosage. After starting methadone therapy or increasing the dosage, systemic toxicity may not become apparent for several days. Some medications alter the absorption or metabolism of methadone, and their concurrent use may require dosing adjustments. Methadone is less expensive than other sustained-release opioid formulations.
ABSTRACT: Opioid analgesics are useful agents for treating pain of various etiologies; however, adverse effects are potential limitations to their use. Strategies to minimize adverse effects of opioids include dose reduction, symptomatic management, opioid rotation, and changing the route of administration. Nausea occurs in approximately 25 percent of patients; prophylactic measures may not be required. Patients who do develop nausea will require antiemetic treatment with an antipsychotic, prokinetic agent, or serotonin antagonist. Understanding the mechanism for opioid-induced nausea will aid in the selection of appropriate agents. Constipation is considered an expected side effect with chronic opioid use. Physicians should minimize the development of constipation using prophylactic measures. Monotherapy with stool softeners often is not effective; a stool softener combined with a stimulant laxative is preferred. Sedation and cognitive changes occur with initiation of therapy or dose escalation. Underlying disease states or other centrally acting medications often will compound the opioid's adverse effects. Minimizing unnecessary medications and judicious use of stimulants and antipsychotics are used to manage the central nervous system side effects. Pruritus may develop, but it is generally not considered an allergic reaction. Antihistamines are the preferred management option should pharmacotherapy treatment be required.
Treatment Options for Insomnia - Article
ABSTRACT: The frequency of sleep disruption and the degree to which insomnia significantly affects daytime function determine the need for evaluation and treatment. Physicians may initiate treatment of insomnia at an initial visit; for patients with a clear acute stressor such as grief, no further evaluation may be indicated. However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. Treatment should begin with nonpharmacologic therapy, addressing sleep hygiene issues and exercise. There is good evidence supporting the effectiveness of cognitive behavior therapy. Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. Hypnotics generally should be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances. Routine use of over-the-counter drugs containing antihistamines should be discouraged. Alcohol has the potential for abuse and should not be used as a sleep aid. Opiates are valuable in pain-associated insomnia. Benzodiazepines are most useful for short-term treatment; however, long-term use may lead to adverse effects and withdrawal phenomena. The better safety profile of the newer-generation nonbenzodiazepines (i.e., zolpidem, zaleplon, eszopidone, and ramelteon) makes them better first-line choices for long-term treatment of chronic insomnia.
Managing Pain in the Dying Patient - Article
ABSTRACT: End-of-life care can be a challenge requiring the full range of a family physician's skills. Significant pain is common but is often undertreated despite available medications and technology. Starting with an appropriate assessment and following recommended guidelines on the use of analgesics, family physicians can achieve successful pain relief in nearly 90 percent of dying patients. Physicians must overcome their own fears about using narcotics and allay similar fears in patients, families and communities. Drugs such as corticosteroids, antidepressants and anticonvulsants can also help to alleviate pain. Anticonvulsants can be especially useful in relieving neuropathic pain. Side effects of pain medications should be anticipated and treated promptly, but good pain control should be maintained. The physical, psychologic, social and spiritual needs of dying patients are best managed with a team approach. Home visits can provide comfort and facilitate the doctor-patient relationship at the end of life.
When a Patient's Chronic Pain Gets Worse - Curbside Consultation
ABSTRACT: A systematic approach to chronic nonmalignant pain includes a comprehensive evaluation; a treatment plan determined by the diagnosis and mechanisms underlying the pain; patient education; and realistic goal setting. The main goal of treatment is to improve quality of life while decreasing pain. An initial comprehensive pain assessment is essential in developing a treatment plan that addresses the physical, social, functional, and psychological needs of the patient. One obstacle to appropriate pain management is managing the adverse effects of medication. Opioids pose challenges with abuse, addiction, diversion, lack of knowledge, concerns about adverse effects, and fears of regulatory scrutiny. These challenges may be overcome by adherence to the Federation of State Medical Boards guidelines, use of random urine drug screening, monitoring for aberrant behaviors, and anticipating adverse effects. When psychiatric comorbidities are present, risk of substance abuse is high and pain management may require specialized treatment or consultation. Referral to a pain management specialist can be helpful.
ABSTRACT: As death approaches, a gradual shift in emphasis from curative and life prolonging therapies toward palliative therapies can relieve significant medical burdens and maintain a patient's dignity and comfort. Pain and dyspnea are treated based on severity, with stepped interventions, primarily opioids. Common adverse effects of opioids, such as constipation, must be treated proactively; other adverse effects, such as nausea and mental status changes, usually dissipate with time. Parenteral methylnaltrexone can be considered for intractable cases of opioid bowel dysfunction. Tumor-related bowel obstruction can be managed with corticosteroids and octreotide. Therapy for nausea and vomiting should be targeted to the underlying cause; low-dose haloperidol is often effective. Delirium should be prevented with normalization of environment or managed medically. Excessive respiratory secretions can be treated with reassurance and, if necessary, drying of secretions to prevent the phenomenon called the "death rattle." There is always something more that can be done for comfort, no matter how dire a situation appears to be. Good management of physical symptoms allows patients and loved ones the space to work out unfinished emotional, psychological, and spiritual issues, and, thereby, the opportunity to find affirmation at life's end.