• Paracetamol – • Aspirin• Nefopam• NSAIDS• Opioids

• Topical – capsaicin, rubifacients, nsaids, Local anaesthetics

What Analgesics?

• Diazepam, methocarbamol.• Amitriptylline• TENS machine• Stretching, massage, physio Osteopathy,

Acupuncture • Antidepressants

Add on’s

WHO's three step ladder to use of analgesic drugs www.who.int/cancer/palliative/painladder

3

1

2

OpioidsWeak Equivalent dose

of MORPHINE

Codeine 30-60mg qdsMAX 240mg/day 40mg / day

Dihydrocodeine 30-60mg qdsMAX 240mg/day 50mg / day

More s/e euphoria etc?

Tramadol 50-100mg qds or s/r formulation

40 – 80mg / day Less predictable

Buprenorphine 5mcg t/d70mcg t/d

10mg / day120mg / day

7 day patch

OpioidsStrong Equivalent dose of

MORPHINE

OXYCODONE Oxycodone 20mg40mg / day

Less s/e resp depression etc.

Fentanyl Patch 25mcg patch100mcg patch

60-100mg / day360mg / day

5 day patch

Morphine

Equivalent strengths of transdermal opioids

(i.e. Don’t mix up your fentanyl with your butrans!)

• 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)

S/e of opiates

• 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

Long-term adverse effects

• 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

Stopping strong opioid medication

• 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 1:

• 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 2

• 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 3

• 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.

Recommendations 4