QUESTION: Many of my home health care and hospice patients need long-term analgesia for chronic or terminal conditions. With so many options available these days, how can I decide what's best for each patient?
ANSWER: To minimize adverse reactions and improve patient adherence to therapy, start with the simplest dosage schedule and the least invasive route that provides adequate analgesia. New extended-release formulations of familiar drugs have dramatically reduced the frequency of dosing for some patients. Here's a quick overview of several effective oral
and topical formulations to consider. Oral ai
OxyContin is a timed-release formulation of oxycodone that allows 12-hour dosing. OxyIR and Oxyfast are fast-acting oxycodone formulations used for breakthrough pain. Previously, oxycodone was available only in combination with acetaminophen or aspirin, which limited the frequency of dosing. Now that oxycodone is available as a single agent, it can be given to manage severe pain without ceiling-dose concerns.
Kadian is a morphine formulation of timed-release particles within a capsule. Administered once or twice every 24 hours, it provides continuous pain relief without requiring the patient to take multiple doses. If the patient can't swallow the capsule, open it and sprinkle the particles on applesauce; you can also give it by gastric or nasogastric tube with adequate fluids.
Duragesic, a fentanyl transdermal system, became available several years ago and extended the opioid dose schedule to 72 hours. Fentanyl is absorbed slowly through the skin. Because it can't be titrated rapidly, this transdermal formulation is most useful for treating stable chronic pain.
Lidoderm patch is a transdermal patch impregnated with 5% lidocaine. Studies show it's effective for various neuropathic pains, including postherpetic neuralgia and neuropathy. You may place a single patch, a portion of a patch, or up to three patches simultaneously on intact skin in the area of pain.
To prevent toxicity, leave the patch in place for 12 hours, then remove it for at least 12 hours. The lidocaine that penetrates the skin is adequate to produce an analgesic effect but not enough to cause anesthesia or a total sensory block to the area.
Even three full-size Lidoderm patches deliver only about one-tenth the dose of lidocaine used to treat cardiac arrhythmias. Even so, use caution in patients receiving Class I antiarrhythmic drugs or other products containing local anesthetics because of possible additive effects and toxicity.
Also, monitor the patient for allergic responses to lidocaine, although these are uncommon.
Actiq is a lozenge formulation of fentanyl citrate used to treat breakthrough cancer pain in opioidtolerant patients. The transmucosal medication is embedded in a white, raspberry-flavored lozenge on a stick. Tell the patient to rub it thoroughly over the buccal mucosa and warn him not to suck on it. He should get pain relief in 5 to 7 minutes, and relief may last 3 to 4 hours.
He may stop using the lozenge when he obtains pain relief, but instruct him not to use the remainder later. He should dispose of the unused medication by holding it under hot running water until it dissolves. He can then discard the stick in regular trash.
Because this drug is rapidly absorbed, don't give it to an opioidnaive patient. The patient should be tolerating a base dose of at least 30 mg of morphine twice a day or using a 50-mcg Duragesic patch for at least a week before initiating treatment with Actiq.
Fentanyl Oralet, a similar product, is available for use in acute care settings. It's effective as a preoperative medication or to prevent pain from such procedures as dressing changes. 0
Copyright Springhouse Corporation May 2001
Provided by ProQuest Information and Learning Company. All rights Reserved