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Edit Comment Close Premium member Presentation Transcript PAIN MANAGEMENT IN PALLIATIVE CARE: PAIN MANAGEMENT IN PALLIATIVE CARE DR.S.SREENIVASARAO MD,C.C.P.P.M, ASSIST PROFESSOR, DEPT.OF ANAESTHESIA, S.V.R.R.G.G.H.&S.V.M.C, TIRUPATIDRUGS USED FOR PAIN: DRUGS USED FOR PAIN THREE GROUPS OPIOID ANALGESICS NON-OPIOID ANALGESICS ADJUVANT ANALGESICSSlide 3: Oral Morphine is the drug of choice for severe cancer pain - WHOACTION: ACTION Activating opioid receptors in the midbrain & turning on the Descending inhibitory system Activating opiod receptors on the second order pain transmission cells to prevent the Ascending transmission of pain signals Activating opioid receptors at the central terminals of C fibers in the spinal cord Activating opioid receptors in the periphary to inhibit the activation of nociceptors & to inhibit cells that may release inflmmatoy mediatorsRESPONSE MEDIATED BY ACTIVATION OF OPIOID RECEPTORS: RESPONSE MEDIATED BY ACTIVATION OF OPIOID RECEPTORS RECEPTOR RESPONSE ON ACTIVATION MUE ANALGESIA,RESP.DEPRESSION, MIOSIS,EUPHORIA, REDUCED GI MOTILITY KAPPA ANALGESIA,DYSPHORIA, PSYCHOTOMIMETIC EFFECTS MIOSIS,RESP.DEPRESSION DELTA ANALGESIAOPIOID ANALGESICS: OPIOID ANALGESICS CLASSIFICATION AGONIST AGONIST-ANTAGONIST MORPHINE PENTAZOCINE CODEINE,OXYCODONE BUTORPHANOL DIHYDROCODEINE NALBUPHINE OXYMORPHONE DEZOCINE PETHIDINE,METHADONE MEPTAZINAL HYDROMORPHONE FENTANYL PARTIAL AGONIST DIAMORPHINE(HEROIN) BUPRENORPHINE TRAMADOL ANTAGONIST NALOXONE NALTREXONEPreparations: Preparations Morphine Inj Tablets liquid Fentanyl Inj Transdermal patches Oral Transmucosal Under clinical trials Nasal spray InhalationsSlide 8: ORAL MORPHINESlide 9: Poppy flower: Rajasthan MP UP Poppy cultivation in IndiaThe Sad Indian paradox: The Sad Indian paradox 2 million Indians like him need oral morphine for pain relief. It reaches less than 1% of the needyPreparations of Oral Morphine Tablets (MST): Preparations of Oral Morphine Tablets (MST) Immediate Release 10mg, 30mg, 60mg Sustained Release 10mg, 30mg Liquid Morphine Oral MorphineHow to use: How to use Start with 5 - 10mg i/r MST Always use q4h with double dose at bed time Additional doses can be given p.r.n. for breakthrough pain If pain relief is not satisfactory, increase by approximately 50% of previous dose Oral MorphineBreakthrough dosing : Breakthrough dosing When flares of pain last for more than few minutes, extra doses of analgesics may be helpful For each breakthrough dose, offer 5% to 15% of the 24-hour dose A breakthrough dose can be offered once Cmax has been reachedHow to use: How to use There is no maximum dose of morphine; the dose can be increased depending on the severity of pain “Pain is the physiological antagonist to the central side effects of morphine.” Oral MorphineHow to use: How to use Always prescribe a laxative (stimulant +/- softener) prophylactically “The hand that prescribes the Morphine should also writes laxatives” Prescribe an anti-emetic prophylactically for the first few days , especially in patients who are already vomiting Oral MorphineExceptions to ‘every four hours’: Exceptions to ‘every four hours’ Renal failure Very elderly > 70 yrs increase dosing interval decrease dosage size Accumulation of M6G leads to enhanced opioid toxicity. Oral MorphineExceptions to ‘every four hours’: Occasional attacks of severe pain Night pain only Oral Morphine Exceptions to ‘every four hours’Slide 19: Initial: Nausea and vomiting Drowsiness Unsteadiness Oral Morphine - Adverse effectsSlide 20: Continuing: Constipation Nausea and vomiting Inactivity drowsiness Dry mouth Oral Morphine - Adverse effects (cont.)Slide 21: Occasional: Urinary retention Myoclonus Itching Oral Morphine - Adverse effectsSlide 22: Signs of overdose: Drowsiness Delirium Myoclonus Oral Morphine - Adverse effectsMisunderstandings about morphine: Misunderstandings about morphine ‘Morphine is dangerous because it depresses respiration’ Double dose at bed time does’nt cause RD Large therapeutic window Drowsiness and delirium prevents from taking further dose Tolerance to respiratory depression develops in course of time Oral MorphineMisunderstandings about morphine (contd): Misunderstandings about morphine (contd) ‘Morphine is addictive’ Several studies have concluded that risk of addiction is far less than 1% Two studies with more than 500 patients who received Heroin for pain relief found that no patient could be documented as having become addicted Twycross, 1974; Twycross, Wald, 1976 Prospective study of 11,882 hospitalised medical patients only 4 patients could be documented as having become addicted as a result of receiving opioid analgesics Porter, Jick, 1980 Oral MorphineSlide 25: Oral Morphine Results of 2 year study in IndiaOpioid dependence: Opioid dependence Physical Psychological dependence dependence (withdrawal symptoms) (addiction) Diarrhoea, palpitation Craving and sweating unsanctioned dose loss of other interestsMNJ experience:: MNJ experience: Addiction: Total no. of patients seen since December 2003- More than 6000 subjects One patient had ? Addiction with h/o high risk behavior Oral MorphineOther misunderstandings about Morphine: Other misunderstandings about Morphine ‘Morphine induces euphoria’ What happens if a person with no pain takes oral morphine? Pharmaco-kinetics of oral morphine Oral MorphineOther Misunderstandings about Morphine: Other Misunderstandings about Morphine ‘ Tolerance to morphine develops rapidly’ ‘ If a cancer patient is given morphine, he is going to die soon’ Oral MorphineOther Indications: Other Indications Intractable Cough Dyspnoea Intractable diarrhoea Oral MorphineConclusions: Conclusions Oral morphine is the drug of choice for severe cancer pain management It is always safe in “safe hands” Respiratory depression, addiction and tolerance are not problems with oral morphine Oral MorphineFentanyl: Fentanyl Convenient 25 times expensive Not useful for break through pain Latency of action Acts up to 24 hrs after removal of patch Titration not possible if the patient becomes drowsy Practically no role as first line It works better in cool climateNON OPIOID ANALGESICS: NON OPIOID ANALGESICS PARACETAMOL NSAIDSParacetamol: Paracetamol Mechanism of action : Anti pyretic Central – inhibits cox in the CNS - intracts with several other central mechanisms like Opioidergic & serotinergic Peripheral analgesic effect No anti inflammatory actionParacetamol: Paracetamol ADVANTAGES DRAWBACKS No Injurity to Gastric mucosa No nephrotoxicity No platelet dysfunction It can be taken by 2/3 rd of patients hypersensitive to aspirin/NSAIDS Safe up to 6-8 g/day Large doses 20mg/m 2 Large size tablets Frequency of administration 4-6 th hourly HepatotoxicityNSAIDS: NSAIDS INHIBIT THE CYCLO-OXYGENASE PHOSPHOLIPIDS ARACHIDONIC ACID PG’S PG’S STOMACH INFLAMMATION PLATELETS STOMACH INTESTINES,KIDNEY KIDNEY BONE,BRAIN COX-1 COX-2 TISSUE DAMAGE PHYSIOLOGICAL STIMULUS CONSTITUTIVE INDUCIMLESlide 37: NSAIDS INHIBIT THE CYCLO-OXYGENASE DECREASING SYNTHESIS OF PROSTAGLANDINS REDUCES THE PAIN SENSITIZING EFFECT OF PG’S ANTI-INFLAMMATORY AND ANTIPYRETIC EFFECTS &ADVERSE EFFECTS: ADVERSE EFFECTS GIT ---ULCERATIONS BLOOD---INHIBITION OF PLETELET AGGREGATION KIDNEY---FLUID &POTASSIUM RETENTION ALL THE ABOVE EFFECTS LEADS TO THREE MAJOR PROBLEMS GI BLEEDING RANAL FAILURE CONGESTIVE HEART FAILURE COMMONLY USED DRUGS IBUPROFEN,DICLOFINAC,KETOROLAC,NAPROXEN,PIROXICAM SELECTIVE COX-2 INHIBITORS---CELECOXIB,VALDECOXIB,ROFECOXIB,ETORICIXIBADJUVANT DRUS: ADJUVANT DRUS Not analgesics, but relieve pain in specific situations Drugs to control the undesirable effects of analgesics Concurrently prescribed psychotropic medicationADJUVANTS: ADJUVANTS Antidepressants like TCA Anti-epileptics NMDA receptor channel blockers Corticosteroids Antispasmodics Muscle relaxants Bispsphonates RadiationNonpharmacologic techniques: Nonpharmacologic techniques neurostimulatory techniques physical therapy psychological approaches art or music therapy massage and body work, etc acupuncture, acupressure, etc.Slide 42: THANK YOU You do not have the permission to view this presentation. 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