Cancer Pain Management: Analgesic Ladder,Opioid Analgesics

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CANCER PAIN MANAGEMENT

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Route of Administration

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Dr Sunita Goel
Lecturer in Anaesthesiology
BJ Wadia Children's Hospital

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ANALGESIC LADDER APPROACH:

Opioids: Effective for most pain types, may require higher doses for neuropathic pain. Add weaker opioid or lower doses of stronger opioids (morphine) at step two of the ladder, increase dose if pain persists or progresses to severe intensity.

Opioid Analgesics (Table 1)

Opioid analgesics used for Rx of chronic pain

	Equianal gesic doses	½ life (hr)	Peak effect (hr)	Dura tion (hr)	Toxicity	Comments
Morphine	10 IM, 20-60 PO	2-3 2-3	0.5-1 1.5-2	3-6 4-7	Constipation, nausea, sedation, most common is respiratory depression (rare in cancer patients)	Standard compound for opioids; multiple routes available
Controlled release morphine	20-60 PO	2-3	3-4	8-12
Sustained release morphine	20-60 PO	2-3	4-6			Once a day morphine
Hydromor phone	1.5 IM, 7.5 PO	2-3 2-3	0.5-1 1-2	3-4 3-4	Same as morphine	Combined with aspirin as acetaminophen for moderate pain; available orally with co-analgesic for severe pain
Oxymor phone	1 IM 10 PO	--	0.5-1 1.5-3	3-6 4-6	Same as morphine	No oral formulation
Meperidine	75 IM 300 PO	2-3 2-3	0.5-1 1-2	3-4 3-6	Same as morphine + CNS excitation; contraindicated in those on MAO inhibitors	Not preferred for cancer due to potential toxicity
Heroin	5 IM	0.5	0.5-1	4-5	Same as morphine	Analgesic action due to metabolites- predominantly morphine
Levorpha nol	2 IM 4 PO	12-15	0.5-1	3-6	Same as morphine	Long ½ life -accumulation occurs after beginning or increasing dose
Methadone	10 IM 20 PO	12- >150	0.5-1.5	4-8	Same as morphine	Risk of delayed toxicity due to accumulation; useful to start dosing on P.V.N basis, with close monitoring
Codeine	130 IM 200 PO	2-3	1.5 - 2	3-6	Same as morphine	Usually combined with non-opioid
Propoxy phene HCl.	-	12	1.5-2	3-6	Same as morphine + seizures with overdose	Toxic metabolite accumulates but not significant as doses used clinically; often combined with non-opioid
Propoxy phene naprylate	-	12	1.5-2	3-6	Same as Hydrochloride	Same as HCl
Hydro codeine	-	2-4	0.5-1	3-4	Same as Hydrochloride	Only available combined with acetaminophen
Dehydro codeine	-	2-4	0.5-1	3-4	Same as Hydrochloride	Only available combined with acetaminophen
Fentanyl	-	7-12	-	-	Same as morphine
Fentanyl trans dermal system	-	6-24	-	48-72

Adjuvant analgesics: (tricyclics antidepressants, anticonvulsants, corticosteroids, local anesthetics). Effective for neuropathic pain, may be added at step 1 and continued on all 3 rings of the ladder.

Next : Route of Administration of Opioid

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