A Practical Approach to Cancer Pain Management

Pain Management Part 2
Use of Adjuvants
John Mulder, MD, FAAHPM
Vice President of Medical Services
Faith Hospice
Director, GR MEP Palliative Medicine
Fellowship Program
Coanalgesic Drugs (Adjuvant Therapy)
Definition: Drugs which enhance analgesic
efficacy of opioids, treat concurrent symptoms
that exacerbate pain, or produce independent
analgesia for specific types of pain.
• Early use optimizes comfort and function by
preventing or reducing side effects of higher
doses of opioids
Coanalgesic Drugs (Adjuvant Therapy)
amenable cancer pain syndromes
Bone metastases
Neuropathic pain
Visceral distention
commonly used coanalgesic drugs
Bone Metastases - Adjuvants
• Steroids
• Decadron 4mg BID, titrate
• Bisphosphonates
• Zometa, Aredia
• Radioisotopes
Neuropatic Pain – Adjuvants
• Tricyclic antidepressants
• Anticonvulsants
• Steroids
Alternative/Adjuvant Medications
• Antidepressants
• TCA - Elavil, gold standard; desipramine
• SSRI - Paxil only one shown
effective thus far; Serzone, Effexor
• Psychostimulants - dietary caffeine, Ritalin,
Alternative/Adjuvant Medications
• Neuroleptics
• Benzodiazapines (watch for sedation)
• Anticonvulsants - especially for neurogenic
pain (Neurontin)
• Baclofen
Alternative/Adjuvant Medications
• Steroids - high dose, short term/low-dose,
long term
• Antihistamines (Benedryl, Vistaril)
• Alpha-2-adrenergic stimulants (Clonidine)
• Cannabanoids
Alternative/Adjuvant Medications
• Capsaicin
• Colchicine
• Thalidomide
• Ketamine
• Lidocaine
• Dextromethorphan - (no guaifenesin or
alcohol) - 30 mg BID - 1 g/d (400 - 600 mg/d
usual )
Narcotic Resistant Pains
• Headaches
• Muscle Spasm
• Tenesmoid (Bowel / Bladder)
• Incident to movement
• Decubitus
• Deafferentation
Deafferention Pain
• Type I Complex Regional Pain Syndrome
A syndrome characterized by severe burning pain in an extremity
accompanied by sudomotor, vasomotor, and trophic changes in
bone without an associated specific nerve injury. ...
• Complex Regional Pain Syndromes
Conditions characterized by pain involving an extremity or other
body region, HYPERESTHESIA, and localized autonomic
dysfunction following injury to soft tissue or nerve. The pain ...
• Reflex Sympathetic Dystrophy Syndrome
A syndrome characterized by severe burning pain in an extremity
accompanied by sudomotor, vasomotor, and trophic changes in
bone without an associated specific nerve injury. ...
Non-pharmacologic Interventions
• Acupuncture
• Acupressure
• Massage Therapy
• Music Therapy
• Hypnosis
• Relaxation
Unwarranted / Exaggerated Fears
• Respiratory Depression
• Addiction
• Rapid Tolerance
• Regulatory Reprisal
Opiate Side Effects: Constipation
– Most common side effect - expected
– Mediated spinally and in GI tract
– Decreased peristalsis & decreased intestinal
– Tolerance does not readily occur
– Treat with peristaltic agent and softeners prophylactically
Opiate Side Effects: Pruritis
Caused by opioid induced histamine release
Tolerance generally develops quickly
Difficult cases may require a change in opioid
Usually treated with transient use of
Opiate Side Effects: Somnolence / Sedation
– Common, but tolerance typically develops within
a few days
– Sedation varies with opioid and dosing schedule
– Additive effects with other cerebral depressants
– Decrease or discontinue other cerebral depressants
– Concurrent use of Dextroamphetamine or
Methylphenidate is helpful, but tachyphylaxis is
Opiate Side Effects: Hallucinations /
– Less common, but may occur especially in
older patients
– Often an indication of excess dosing
– Try dose reduction or different opioid
Opiate Side Effects: Nausea / Vomiting
– Occurs in 50 – 65% of patients on oral
– Varies with drug and route
– Usually easy to control, occasionally severe and
difficult to control
Opiate Side Effects: Urinary Retention
– Opioids increase smooth muscle tone
– May also cause bladder spasms
– Try changing opioids or insertion of catheter
Opiate Side Effects: Myoclonus
– Can occur with all opioids
– Typically due to high doses and/or dehydration
– Long half-life metabolites are typically
– Reduce dose, change opioids, change routes
and/or hydrate patient
Opiate Side Effects: Respiratory Depression
– Cause of death in opioid overdose
– Tolerance develops rapidly
– Rarely a concern with appropriate dose
– If accidental overdose occurs in a patient
chronically receiving opioids, dilute Naloxone
1:10 and titrate very carefully to reverse
respiratory depression without precipitating
withdrawal or reversing analgesia

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