Page 156 Guide to Pain Management in Low-Resource Settings

144 Andreas Kopf

intake of coff ee, or from chewing coca leaves (in the radiochemotherapy and those who are at ad-
Andean mountains in Latin America) or khat (in the vanced stages of disease.
Arab Peninsula and East Africa). • Opioids should only be prescribed by one person.
• Patients and their relatives should—before start-
Pearls of wisdom ing the opioid medication—receive an education
on the pros (nontoxic, long-term use) and cons
• Morphine is still the opioid of fi rst choice. (no stopping therapy without consulting the pre-
• Th e preferred route of application is oral. scriber, no change of doses without consultation
• In patients needing long-term parenteral opioids, of the prescriber) of opioids.
subcutaneous administration should be preferred. • When initial pain readings are high, intravenous
• Opioids should be used early on and not as the titration of morphine may be used to estimate
last resort of therapy. the (additional) daily opioid requirements of the
• Th ere is no advantage to using “weak” opioids like patient (this only applies to cancer patients!). Th e
codeine or tramadol; therefore—if only morphine cumulative dose of i.v. morphine that is necessary
is available—morphine or other “strong” opioids to achieve acute pain control multiplied by 12 will
may be used fi rst. roughly give the daily oral dose of morphine the
• Opioids should be combined with NSAIDs, dipy- patient will need in the days to come. Th e next
rone, or paracetamol (acetaminophen) to reduce consultation should be within the next few days
the dose and side eff ects of opioids. to reevaluate the patient.
• If neuropathic pain is the leading symptom, co- • When pain readings are high, but pain is not ex-
analgesics such as amitriptyline or gabapentin cruciating, a dose increase of roughly 25–50%
should be added where available. will be adequate, and the next consultation
• All opioid medication should consist of a fi xed- should be within a few days to reevaluate the pa-
dose regimen and an on-demand dose. If avail- tient.
able, the fi xed dose should be a slow-release • Opioid-naive patients should expect sedation and
opioid and the on-demand dose an immediate- nausea. Nausea should be treated prophylactically
release opioid. for about one week (e.g., with metoclopramide,
• Th e on-demand dose should be calculated from when available).
the fi xed-dose regimen (around 10% of the cumu- • Always educate patients about the constipating
lative daily dose of opioid). eff ects of opioids and advise them to take laxa-
• Th e on-demand dose may be used by patients as tives.
often as they need it, with a 30–45 minute mini- • Transdermal opioid patches—if available—are
mum wait before the next on-demand dose. only indicated in patients with stable dose re-
• If more than four on-demand doses are used quirements of opioids and have to be combined
daily on average, the fi xed daily dose should be with on-demand doses.
increased by 75% of the cumulative daily on-de-
mand dose. References
• If the sedating and nauseating side eff ects of the
fi rst opioid used last longer than 2 weeks and the [1] Agency for Health Care Policy and Research. Clinical practice guideline.
Management of cancer pain. Available at: http://www.painresearch.
daily dose cannot be reduced due to the patient’s utah.edu/cancerpain/guidelineF.html.
[2] Klaschik E, Nauck F, Ostgathe C. Constipation—modern laxative thera-
analgesic requirement, the opioid should be ro- py. Support Care Cancer 2003;11:679–85.
tated to another opioid, which might have a more [3] Kulke MH. Metastatic pancreatic cancer. Curr Treat Options Oncol
2002;3:449–57.
favorable individual side-eff ect profi le for the pa- [4] Mercadante S. Opioid rotation for cancer pain: rationale and clinical as-
tient. pects. Cancer 1999;86:1856–66.
[5] Mercadante S, Nicosia F.Celiac plexus block: a reappraisal. Reg Anaesth
• Alternative routes of application for opioids (e.g., Pain Med 1998;23:37–48.
[6] Müller-Lissner S. Th e diffi cult patient with constipation. Best Pract Res
parenteral or intrathecal) are never required in Clin Gastroenterol 2007;21:473–84.
the normal course of cancer and are seldom re- [7] Nersesyan H, Slavin KV. Current approach to cancer pain management:
availability and implications of diff erent treatment options. Th er Clin
quired in patients undergoing sophisticated Risk Manag 2007;3 381–400.