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Healthcare Professionals' Page
Pain Management
Principles
1. Use a multidrug
approach. Combine Opioids with non-opioid
adjuvants. A stepped approach is recommended
(see below).
2. Opioids should be limited to the agonist
drugs. Avoid Meperidine (Demerol) and the mixed
agonist - antagonist opioids (e.g.
Stadol, Nubain,
Talwin).
3. Cancer pain is chronic in nature and
requires, with the rare exception, both scheduled and rescue dosing.
Scheduled dosing will maintain even serum drug levels and provide
consistent relief. Rescue dosing should be available on an as-needed basis
and can be increased or decreased depending on its effects. Frequent
rescue dosing requires a change in the scheduled long acting drug dose.
4. Base
the administration schedule on the analgesic’s duration of effect. If
possible, use sustained release opioids for
scheduled dosing and always use immediate release
opioids for rescue dosing.
5. A noninvasive route is preferred. For pain
that is severe and escalating, it may be necessary to provide intravenous
analgesics until the pain is managed. If oral, rectal, or
transdermal dosing is no longer practical or
appropriate, continuous subcutaneous or intravenous infusions are
indicated.
6. Take into account the
equianalgesic differences of the various routes of administration.
The first pass effect of hepatic metabolism requires higher oral
opioid dosing than
parenteral dosing. When changing from oral to
parenteral or when changing opiates, allow for individual
differences, and then titrate dose to pain
relief.
7. Manage opioid
side effects aggressively. Be mindful that patients never become tolerant
to the constipating effects of opioids.
Pain Levels
STEP 3
Severe Pain
(rating 8-10)
Morphine, hydromorphone, oxycodone, fentanyl, or methadone
Pain may require oral, transdermal, parenteral, or intraspinal routes for
adequate analgesia. Invasive techniques should be considered for patients
who do not respond to Step 3.
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STEP 2 Moderate Pain
(rating 4-7)
Acetaminophen/oxycodone combination (Percocet)
Acetaminophen/hydrocodone combination (Vicodin)
Immediate (OxyIR) or sustained release oxycodone (Oxycontin)
When the maximum tolerated or recommended dosage is reached, or pain is
unresponsive proceed to step 3 interventions.
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STEP 1 Mild Pain
(rating 1-3)
Acetaminophen or an NSAID (e.g. ibuprofen)
When the maximum tolerated or recommended dosage is reached, or pain is
unresponsive, proceed to step 2 interventions.
At each level adjust or add: 1) nonpharmacologic interventions and/or 2)
psychosocial support
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