Moderate cancer pain Analgesic treatment is selected according to their VAS score. Mild opioids are the basis of treatment (in combination or not with drugs described in the first step). Step 2 includes codeine, dihydrocodeine, and tramadol. All of these compounds are available in controlled- release forms. Low doses of transdermal fentanyl and buprenorphine can also be considered. Some studies have shown that effectiveness at the second step of the WHO ladder lasts for about 1 month for most patients due to insufficient analgesia. Since weak opioids have a therapeutic ceiling, some authors have proposed abandoning their use in moderate pain in favor of early initiation of the third step with low doses of strong opioids. Low doses of strong opioids together with nonopioid drugs can be weighed as an alternative to mild opioids. Management of side effects Clinicians are advised to look out for the main toxicities associated with opioids including GI (constipation, nausea, vomiting), CNS (cognitive impairment, hyperalgesia, allodynia, and myoclonia), respiratory depression, and others (pruritus, dry mouth, urinary retention, hypogonadism, and immune depression). Management includes the following: a. Patient information and prophylactic measures b. Reduction in opioid dose through the use of a co- adjuvant and/or first-step drug c. Pharmacological strategies, such as antiemetics for nausea, laxatives for constipation, tranquilizers for confusion, and psychostimulants for drowsiness d. Switching to another opioid or route. For persistent constipation, consider PAMORAs (peripherally acting mu-opioid receptor antagonists) with demonstrated benefit in non-oncological settings. Case study 5 Conceived under normal reproductive conditions and birthed at term, Edwin Junior enjoyed a peaceful life condition from his birth to age 15. Like every other teenager living with a family in the countryside in Haiti, he had a fair share of subsistent farming assistance, radiant sunlight, a diet of mainly dairy products and carbohydrates, and a small circle of friends to play with on the farmland. Edwin’s first life trauma occurred in late 2015, 2 weeks after his 15th birthday, when a wildfire destroyed the Tyrinoise farmland— his family’s homestead. Edwin was sleeping in a small hut as the fire raged on. In the aftermath of the fire, he sustained third-degree burns to the chest and the upper left limb. A few hours after the incident, Edwin was airlifted to a neighboring hospital and immediately admitted into the Burns Emergency Unit. He was subsequently prescribed: ● Acetaminophen 15mg/kg qds. ● Ibuprofen 10mg/kg tds. ● Oramorph 200mcg/kg 4 hrly. ● Initial pain assessment. The burn injury covered approximately 14% of the body surface area and required debridement and split skin grafts under general amnesia. When the plastic surgery team explained the procedural operations of a proposed skin graft with his parents present, Edwin could only murmur a teary contribution: “that sounds very painful?” Recognizing a need for an initial pain assessment for the procedure, the plastic surgery team invited the pain team for a review. An assessment was subsequently conducted
Severe cancer pain Strong opioids are the cornerstone of analgesia in this setting. Morphine, methadone, oxycodone, hydromorphone, fentanyl, and buprenorphine are the most widely used in Europe. The available evidence suggests that oral morphine, hydromorphone, oxycodone, and methadone provide similar efficacy. Neuropeptides such as enkephalins, dynorphins, and endorphins interact at opioid receptors (MOP; DOP; KOP; NOP) located in the CNS, pituitary, and GI tract. Opioid agonists lock onto receptors, blocking neurotransmitter release. Opioid agonists lock onto receptors, blocking the release of neurotransmitters. Opioids differ in affinity, pharmacokinetics, physicochemical properties, side-effect profiles, administration routes, tolerance, and immunomodulation propensity. Opioid rotation Opioid rotation is defined as the substitution of a potent, previously prescribed opioid for a potent alternative opioid with the specific objective of obtaining better analgesia and/or reducing unacceptable toxicity. Patients with cancer who experience pain often require changes in opioid therapy during the disease because of disease progression, pain characteristics, and prolonged use of opioids. The practice of opioid rotation is often successful although the scientific evidence remains poor because of a lack of controlled studies. The goal of equianalgesic rotation is to obtain the amount of opioid in the new prescription that equals the amount administered in the previous form of administration, to avoid over- or under-dosing. Adjuvant therapy Adjuvant therapy consists of drugs that are not primarily used as analgesics but that possess analgesic or additive properties to opioid analgesia. Therefore, they reduce opiate doses, as well as their adverse effects, and can be used at any stage of the analgesic ladder. 24 hours before the procedure. Using the Numerical Rating Scale, Edwin’s pain report described a pain score of 6/10 at rest and 8/10 when the pain team touched his arm. Edwin’s score also suggests strong evidence of peri-procedural fear and pain-related anxiety. The pain team on report submission stressed the need to ensure adequate baseline analgesia before a skin graft in a teenager who had displayed heightened anxiety about procedural pain. As a recommendation, the pain team also suggested the plastic surgery team utilize all six doses of Oramorph and make provision for on-the-clock pain The plastic surgery team, upon recognizing the need for adequate pain therapy as advised, developed a therapy plan primarily including a procedural analgesic agent and a procedural anxiolytic agent. ● Opiates: Fentanyl (administered intranasal) 1.5–2 mcg/ kg. ● Nitrous Oxide: Entonox (inhaled) titrated to effect. ● NMDA Antagonist: IV Ketamine 0.1–0.3 mg/kg. ● Benzodiazepines: PO Temazepam 10 mg. ● a2-agonist: Dexmedetomidine Buccal 1–4 mcg/kg (max 100mcg). Edwin’s case effectively described how procedural pain management in young adults can be executed with a direct emphasis on risk factor assessment and collaborative interaction between medical teams. assessments. Medications
Book Code: PYCA2725
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