What Analgesics?
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•
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Paracetamol –
Aspirin
Nefopam
NSAIDS
Opioids
• Topical – capsaicin, rubifacients, nsaids, Local
anaesthetics
Add on’s
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Diazepam, methocarbamol.
Amitriptylline
TENS machine
Stretching, massage, physio Osteopathy,
Acupuncture
• Antidepressants
3
WHO's three step ladder to
use of analgesic drugs
www.who.int/cancer/palliat
ive/painladder
2
1
Opioids
Equivalent dose
of MORPHINE
Weak
Codeine
Dihydrocodeine
30-60mg qds
MAX 240mg/day
30-60mg qds
MAX 240mg/day
40mg / day
50mg / day
More s/e
euphoria etc?
Tramadol
50-100mg qds or
s/r formulation
40 – 80mg / day
Less predictable
Buprenorphine
5mcg t/d
70mcg t/d
10mg / day
120mg / day
7 day patch
Opioids
Equivalent dose of
MORPHINE
Strong
OXYCODONE
Oxycodone 20mg
40mg / day
Fentanyl Patch
Morphine
25mcg patch
100mcg patch
60-100mg / day
360mg / day
Less s/e resp
depression etc.
5 day patch
Equivalent strengths of transdermal
opioids
(i.e. Don’t mix up your fentanyl with
your butrans!)
S/e of opiates
• 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)
Long-term adverse effects
• 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
Stopping strong opioid medication
• 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
Recommendations 1:
• 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 2
• 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 3
• 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 4
• 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.