Promised I'd get the detailed answer in list form for her & email it STAT. I've just looked up a lot of painkillers on this site but don't know in which order I should list them. Methadone has also been listed: would either this or marijuana (which has also been recommended for her pain) give her substantial relief ? She is in great pain and does not have the luxury of time to experiment. However, she needs to hold each Rx back as long as possible in order to save the strongest meds for the pain to come. Thx in advance!!
I work as a nurse in a long term care facility. I have seen many pain meds used as not everything works for everyone. Usually by end stages patients are being given shots of dilaudid on an hourly basis. Morphine is also used through out the day. I also have many patients given the fentynal patch fentynal is said to be 1000 times stronger than morphine its measured in mcg not mg. I have herd of methadone being used for pain, I would bever recommend it however under these circumstances it can be tried but it doesn't work for everyone.
Oxycontin also works for many people its often used with morphine or dilaudid for break through pain.
I would suggest a fentynal patch changed every 48 hours instead of the usual 72hours along with dilaudid for break through pain.
Dilaudid is also used for phantom pain in many cases
Always consult your doctor before taking these meds of course as they are dangerous. I know she doesn't have the time to experiment but she will need to start at a low dose and work her way up if needed
It's possible to stick with just a few medications at different strengths. Look into Fentanyl "lollipops" and Fentora. There's also Oxycontin Instant release. Opana ER, MS Contin are a little weaker (in my opinion only) My dad was on the liquid morphine that helped him a lot. You could also consult with a pain specialist. They may be willing to do a consultation and give you a game plan (so to speak) I wish your friend the very best and my best wishes to you too. You are a very good friend for researching this for her.
These are recommendations from WHO - if she is terminal she needs proper management by a skilled professional.
"The successful drug management of pain relies on selecting the appropriate drug at the correct dosage, and balancing efficacy against adverse effects. For this reason, the World Health Organisation introduced the concept of the analgesic ladder. Oral analgesics are usually the first line.
Drugs should be introduced in the following order:
Step one - Non-opioid analgesics (e.g. aspirin, paracetamol, NSAIDs). If anticipation of pain can be abolished, it may not be necessary to step up to opioids. Give non-opioids regularly and use adjuvants if necessary.
Step two - mild opioids (e.g. codeine) with or without non-opioid:
Codeine - effective for the relief of mild to moderate pain but is too constipating for long-term use.
Dihydrocodeine - efficacy similar to codeine. Can be given 4 hourly.
Doses may need to be adjusted individually according to the degree of analgesia and side-effects. If necessary, step up to morphine, or fentanyl (to initiate, consider involving specialist in palliative care). Arrange for doses to be given at regular intervals - "by the clock", rather than "as required" using the oral route whenever possible.
Step three - strong opioids with or without non-opioid:
Useful for moderate to severe pain particularly of visceral origin. Long-term prescribing commonest for palliative care in malignant disease but also may be appropriate for chronic non-malignant conditions in conjunction with specialist advice.
One of the main reasons patients in severe pain do not receive adequate analgesia is fear of addiction. If the condition is terminal cancer, this is not an appropriate concern.
Main side effects of all opioids are nausea, vomiting, constipation, drowsiness. Respiratory depression and hypotension in larger doses. Such adverse effects should be anticipated, aggressively treated, and regularly reassessed.
Which Strong Opioid?
Most valuable for severe pain, though nausea and vomiting frequent
Additional beneficial effects - detachment and euphoria
First line oral medication for severe pain in palliative care
Give by mouth as an oral solution or as standard ('immediate release') tablets regularly every 4 hours, the initial dose depending largely on the patient's previous treatment
Increase next dose by 50% if the previous dose no more effective than preceding analgesic
Choose the lowest dose which prevents pain and consider adjuvant analgesics (e.g. NSAIDs)
In the case of the modified-release tablets give half the total 24-hour dose (which is then divided into 6 portions to be given every 4 hours)
Titrate stepwise depending on response
Omit overnight dose if double the usual dose given at bedtime
Consider rescue doses for breakthrough pain and prophylactic doses 30 minutes before potentially painful procedure (e.g. dressing changes)
Once daily requirement established, give total dose od or bd (use appropriate modified-release preparation)
If required, increase strength of dose, not frequency of administration
Give the first dose of modified-release preparation 4 hours after last oral dose
Opioid doses should be calculated and checked with care
If oral administration is not tolerated, alternatives include intravenous, continuous subcutaneous, transdermal patches, or rectal route (morphine suppositories)
Give an adequate dose which effectively relieves pain
IM morphine should be given at half the oral solution dose
Diamorphine (heroin) - may cause less nausea and hypotension than morphine
Greater solubility allows effective doses to be injected in smaller volumes and this is important in the emaciated patient
Diamorphine can be given in a smaller volume, IM or subcutaneous, approximately a third of the oral dose of morphine
Subcutaneous infusion of diamorphine via syringe driver is another option
Substitute oral morphine if patient can resume taking medicines by mouth
Steep escalation of opioid doses (e.g., by 100 times or more) may be required, particularly among patients with spine or central nervous system metastatic tumours
When reducing or stopping opioids, doses should be tapered gradually to avoid causing severe pain flare or withdrawal symptoms
Enables prompt analgesia, but short duration of action
Less constipating than morphine, but less potent
Not suitable for severe continuing pain (build up of metabolite norpethidine can cause tremor, confusion and convulsions)
Used rarely in children, but sometimes given IV for short surgical procedures - e.g'. eye surgery
Less sedating than morphine and acts for longer periods
Risk of accumulation and overdose if administered more than twice a day long term
May be used instead of morphine when excitation (or exacerbation of pain) occurs with morphine
This has opioid effect and causes an enhancement of serotonergic and adrenergic pathways.
There are fewer of the typical opioid side-effects (notably, less respiratory depression, less constipation and less addiction potential).
Psychiatric reactions have been reported.
A recent report from the Swedish Medical Products Agency states that withdrawal reactions may be a bigger problem than previously thought. The Swedish adverse reactions database (SWEDIS) contains 71 reports of abstinence/withdrawal symptoms with tramadol, 25 of which were also classed as dependence, habituation or increased tolerance. Treatment duration ranged from 1 week to more than 3 years at dosages of 50-2999 mg. This means that withdrawal symptoms are possible at low/normal doses, and after treatment periods of <6 months.5
Opioid agonist and antagonist properties and may precipitate withdrawal symptoms, including pain, in patients dependent on other opioids
However, longer duration of action than morphine and sublingually is an effective analgesic for 6 to 8 hours
Vomiting may be a problem
Alfentanil, fentanyl and remifentanil - used by injection for intra-operative analgesia. Fentanyl is available at a transdermal patch and has a 72 hour duration of action. This makes it useful in palliative care but it is significantly more expensive than morphine. A new matrix patch which has 35-50% less fentanyl than those currently available appears to be as effective and safe as other standard oral and transdermal opioid treatments.6 Fentanyl appears to be effective in both older and younger age groups.7
See monographs of individual drugs for further details.
Antidepressants - low-dose antidepressants (e.g. amitriptyline 75-150 mg nocte) useful for controlling neuropathic pain. Older tricyclics better than newer SSRIs. If benefit is going to occur, it is usually seen within one week.
Anticonvulsants, most commonly carbamazepine, also useful for neuropathic pain.10 Gabapentin and pregabalin are also licensed for this use. Main indication diabetic neuropathy, trigeminal neuralgia, but also in shooting pain which does not respond to antidepressants, e.g. phantom limb pain.
Muscle spasm - consider a muscle relaxant such as diazepam or baclofen.
Nerve compression may be reduced by a corticosteroid such as dexamethasone, which reduces oedema around the tumour, thus reducing compression.
Block nerve conduction reversibly
Frequent blocks sometimes effect a permanent cure
Regional blocks have been used to good effect in shoulder pain, intercostal neuralgia, postoperative scar pains and other peripheral neuralgias
Epidural steroids and facet joint blocks:
Commonly used for chronic back pain
Trials show statistically significant improvement for up to one year
Not known whether addition of steroid to local anaesthetic is essential
Better results obtained the earlier the patient is treated and in patients who have not had spinal surgery
May take up to a week for benefit to be felt
Worth repeating if short-lived relief, and a course of three injections is often recommended
Facet joint injection with local anaesthetic and steroid is indicated when pain is worse when sitting, and pain is provoked by lateral rotation and spine extension
TENS - rationale is the gate theory. Limited efficacy in acute pain. Patient education in use of technique is important. Many trials, but no systematic reviews.
Neurolytic blocks - aimed at destroying nerves conducting pain by cutting, burning or damaging . Plasticity theory counsels against this approach due to ability of CNS to 're-wire' but have a place in cancer pain when there is short prognosis, or where alternatives not helping or possible.
Surgery - neurosurgical interventions often used for orthopaedic pain - e.g include dorsal column stimulation, rhizotomy, cordotomy and dorsal root entry zone (DREZ) lesions. Some controversy about long-term efficacy."
- Methadone Information for Consumers
- Methadone Information for Healthcare Professionals (includes dosage details)
- Side Effects of Methadone (detailed)
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