Painkillers for Oncology

Update: October 2018

Both acute and chronic types of pain require
medical assistance. Chronic pain syndrome
cancer has its own characteristics:

  • May develop in a short time (due to compression of the nervous
    trunks growing tumor or rapid massive destruction
    body).
  • May exist almost constantly due to re-nudging
    nervous system.
  • May persist even after removing its source (due to
    breakdowns in the braking system of nerve impulses).

Therefore, even at the stage of the absence of any sensations, but
a proven diagnosis of malignancy
developed tactics of phased anesthesia – from weak to severe
active drugs.

By the time the pain appears or becomes worse, the doctor and
the patient must be armed with a ready-made strategy that can
be used in this particular cancer patient with
meeting the required time limits for increasing the dosage of drugs or
enhance the analgesic effect.

Evaluation of cancer pain

The level of pain can be adequately assessed only by those who
is experiencing. In addition, patients experience different feelings:
drilling, sting, tingling, ripple, burning, etc. In order
so that these experiences are better understood by the doctor, use a visual scale
pain levels (see figure).

Шкала болевых уровней для выбора обезболивающего при раке

Scale of pain levels from 0 to 10

By origin of pain in oncology are:

  • Visceral pain. When tumors in the abdominal cavity.
    Feelings of squeezing, fullness, aching or dull, not having
    clear localization.
  • Somatic pain. Develop in vessels, joints, bones,
    nerves Long, dull pain.
  • Neuropathic pain. Occur with damage to the nervous
    Systems: central and peripheral.
  • Psychogenic pain. Appear against the background of depression, fear,
    self-hypnosis without any organic damage like
    painkillers generally do not help here.

What to do?

In case the oncology is confirmed histologically, there is
The diagnosis and the patient is observed by the oncologist:

  • at the stationary stage, the department is responsible for anesthesia;
    where a person is operated on or treated,
  • if the patient in the clinic is observed by the therapist, and in
    Oncologist oncologic dispensary or referred to the doctor for observation
    antitumor clinic clinic, it should be together with
    with all extracts and medical records contact an analgist (more often
    just in oncologic dispensary). This should be done, even if there is no pain.
    An analgist paints a phased pain relief scheme, which
    the doctor will be observing the patient.

If cancer is not confirmed yet – no histology confirmed.
diagnosis, but there is pain – it is also worth contacting an analgist and
receive written recommendations in the medical records
(record in the out-patient card, an extract).

  • If the analgologist has not yet been contacted, but there is pain –
    contact your local GP. In his power to appoint
    non-narcotic analgesics and related drugs that remove
    or relieving pain.
  • If previously used non-narcotic analgesics, but their
    effect is not enough, you should immediately get recommendations
    an analgist who is referred to a therapist at the place of residence,
    less often – to the doctor of the polyclinic antitumor cabinet.

Without a prescription today in the pharmacy you can get unless
nonsteroidal anti-inflammatory (below there is an instruction how
get the necessary painkillers for the patient in a timely manner
cancer).

Standardized pain relief regimens

At each examination of a cancer patient, the attending physician
assesses his subjective sensation of pain and in the appointment
painkillers moving up the three-step stairs from the bottom up. Not
be sure to move the stairs in succession. Presence strong
unbearable pain immediately involves the transition to stage 3.

Обезболивающие средства при онкологии, раке

Stage 1 – mild pain Stage 2 – severe pain Stage 3 –
unbearable pain

First stage – mild pain

At the first stage of anesthesia for oncology are located
nonsteroidal anti-inflammatory drugs with pain medication
effect (ibuprofen, ketoprofen, diclofenac, celecoxib,
Lornoxicam, Nimesulide, Etoricoxib, Meloxicam) or
Paracetamol.

Oncology pain pills

  • Start with the lowest doses (see table) with gradual
    increase if necessary.
  • Since the effect of painkillers is cumulative,
    instant, a few days should not exceed the original
    dose.
  • You need to start with the tablet form, then move on to
    injections. With contraindications to oral administration or the effect of
    pills low, you need to enter pain medication
    intramuscularly.
  • Take pills after meals, under the guise of omeprazole and its
    analogues, you can drink milk, in order to avoid damage to the mucous
    stomach.

First Stage Injections

For all types of cancer pain, except bone pain:

  • Кетанов (или более эффективный
    Кеторол), в separate syringe.
  • Папаверин для усиления эффективности. If a
    the patient smokes, then papaverine will be ineffective.

For bone pains:

  • Neither papaverine nor Ketanov will be compared in effectiveness with
    костных болях с Пироксикамом, Мелоксикамом,
    Ксефокамом
    . Choose one of the drugs and enter in
    separate syringe.
  • With primary bone tumors or metastases in them
    It is advisable to discuss the use of bisphosphonates with your doctor.
    radiopharmaceuticals, Denosumab. In addition to the painkiller, they
    have a therapeutic effect.

If a больной не страдает пониженным давлением и температура тела
нормальная, то показаны Реланиум, Сибазол.

Reinforce the above means can
auxiliary

  • anticonvulsants – Carbamazepine, Pregabalin (Lyrica),
    Lamotrigine,
  • central muscle relaxants – Gabapentin (Tebantin),
  • tranquilizers – Clonazepam, Diazepam, Imipramine.
    Improve sleep, have a sedative effect, strengthens the effect
    narcotic analgesics.
  • кортикостероиды  — Преднизолон, Дексаметазон. Increase
    appetite, in combination with painkillers give effect for pain in
    spine, bone, pain of internal organs.
  • Neuroleptics – Galaperidol, Droperidol, increase analgesics and
    are antiemetic.
  • anticonvulsants – Clonazepam, effective for shooting
    pain, increases narcotic analgesics.

Second stage – moderate to severe pain

Because first-stage drugs become poorly effective
Paracetamol (or nonsteroidal anti-inflammatory) is required in
combination with weak opioids (codeine or
Tramadol).

With such pains, pills are often prescribed for oncology:

  • Tramadol – it is prescribed in the first place, precisely when
    non-narcotic pain medications already help. It applies either to
    tablets (often causes nausea) or injections. Together with
    NSAIDs (Paracetamol, Ketorol). Tramadol should not be taken along with
    narcotic analgesics and with MAO inhibitors (Fenelzin,
    Iproniazid, Oklobemid, Selegilin).
  • Zaldiar is a complex preparation of Tramadol and Paracetamol.

Injections:

  • Tramadol + Relanium (in different syringes)
  • Tramadol and diphenhydramine (in one syringe)
  • Codeine + Paracetamol (max. Daily intake 4-5 thousand
    mg.).

To achieve the effect and at the same time reduce pain as much as possible.
fewer drugs need to be combined
Codeine or Tramadol with other NSAIDs (Paracetamol, Ketorol and
etc.).

Further, Paracetamol may be prescribed with small doses.
Fentanyl, Oxycodone, Buprenorphine, Related to Strong
opioid analgesics. The combination is reinforced and auxiliary
therapy from the first stage.

Third Stage – Severe Pain

With severe pain or persistent pain, for example, at stage 4,
high doses of Tramadol or Codeine no longer help. Oncological
the patient needs strong opioids in combination with Paracetamol and
auxiliary миорелаксантами или транквилизаторами.

Morphine – a drug that is prescribed in oncology
intolerable pains. In addition to the analgesic effect, it has everything
strong drug side effects (addiction, addiction),
after applying it, there will be nothing to help, there will be no
choice of means. Therefore, to move from the weak (Tramadol) to more
strong should be very balanced.

List of analgesics that are desirable to apply before
Morphine:

 A drug Effectiveness relative to morphine Act
Tramadol 10-15% 4 hours
Codeine 15-20% 4-6 hours
Trimeperidine (Promedol) 50-60% 4-8 hours
Buprenorphine (Bupronal) 40-50% 4-6 hours
Pyritramide (Dipidolor) 60% 6-10 hours
Fentonil (Duragesic) 75-125 times more efficient 6 or more
Morphine 4-5 hours

The list of narcotic painkillers from weaker to more
strong:

  • Tramadol – по некоторым источникам считается синтетическим
    analogue of drugs, for other non-narcotic analgesics.
  • Trimeperidine – in tablets, the effect is 2 times lower than
    инъекционных, меньше побочных действий в сравнении с Morphineом.
  • Buprenorphine – addiction and dependence develop more slowly,
    than morphine.
  • Pyritramide – action is very fast (1 minute), compatible with
    neurotropic drugs.
  • Fentonil is more convenient, painless and effective to use in
    patch, not in / muscular or in / venno.
  • Morphine –  эффект наступает через 5-10 мин.

The doctor should offer these drugs to the patient, but as a rule,
need to take the initiative to relatives of the patient and discuss with him
the ability to use less non-narcotic drugs
сильные опиаты, чем Morphine.

The choice of method of administration

  1. Tablets oncology and capsules are convenient almost
    always, except in cases of difficulty swallowing (for example, in case of cancer
    stomach, esophagus, tongue).
  2. Cutaneous forms (patches) allow for progressive absorption
    drug without irritation of the mucous membranes of the gastrointestinal tract and sticking plaster one
    once every few days.
  3. Injections are more often performed intracutaneously or (when there is a need for
    rapid elimination of pain) intravenously (for example, cancer
    intestine).

For any route of administration, dosage selection and feed rate
medication is administered individually with regular quality control.
pain relief and the presence of undesirable effects of substances (for this
examination of the patient is shown at least once every ten days).

Injections

  • Pain relief injections представлены: Tramadolом, Тримеперидином,
    Фентанилом, Бупренорфином, Буторфанолом, Налбуфинлм, Morphineом.
  • Комбинированным средством: Codeine + Morphine + Носкапин +
    Papaverina hydrochloride + Tebaine.

Tablets, capsules, drops, patches

Notинъекционные варианты опиоидных обезболивающих:

  • Tramadol в капсулах по 50 mg, таблетках по 150, 100, 200
    milligrams, rectal suppositories, 100 milligrams each, drops to take
    inward
  • Парацетамол + Tramadol капсулы 325 мг + 37,5 milligram,
    325 mg coated tablets + 37.5 MIDs,
  • Dihydrocodeine tablets of the prolonged action 60, 90, 120
    mg,
  • Propionylphenylethoxyethylpiperidine in cheek tablets of 20
    milligram,
  • Buprenorphine skin patch 35 µg / hour, 52.5 µg / hour, 70
    mcg / hour
  • Бупренорфин + Налоксон подъязычные таблетки 0,2 мг/0,2 mg,
  • Oxycodone + Naloxone and long-acting tablets with
    sheath 5 mg / 2.5 mg; 10 mg / 5 mg; 20 mg / 10 mg; 40 mg / 20
    mg,
  • Tablets of tapentadol with prolonged film coating
    высвобождения вещества по 250, 200, 150, 100 и 50 milligram,
  • Trimeperidine tablets,
  • Fentanyl skin patch 12.5; 25; 50, 75 и 100 mcg / hour
    sublingual tablets.
  • Morphine капсулы длительного высвобождения 10, 30, 60, 100
    milligram, таблетки пролонгированные с оболочкой по 100, 60, 30
    milligram.

How to get painkillers

Appointment of light opioids is signed by the medical officer once, then
re-discharge can be done by the doctor. Re-started
Looks at the argument of changing the dose or switching to another drug.
(for example, gain).

Today, if there is a normal recommendation
an alnalgologist (stepwise enhancement of therapy), then move on it and
no one waits for a long time:

  • Kohl Ketorol, less often Diclofenac, then immediately go to
    Tramadol (при усилении болей).
  • Трехкратный прием Tramadolа в сочетании с парацетамолом и
    Gabapentin with no effect – switch to Durgesic (Fentanyl).
  • After increasing the dosage to the maximum or impossibility
    use of patches – go to morphine.

Cutaneous options – Fentanyl anesthetic patches and
Buprenorphine is the preferred alternative.
preformed opioids. It is a strong painkiller with gradual
drug release. The question of their destination rests on
price tag and availability.

  • If a у пациента имеется группа инвалидности, и он имеет право
    on preferential drug provision

the issue of discharge of the same Fentanyl (Durgezik) is carried out by
place of residence by a district physician or surgeon
antitumor study (in the presence of recommendations from an analgist,
filling out the documentation – preferential recipe and its copy signed
medical institution at the primary discharge of the drug). AT
further, the district therapist may discharge the medication
independently, referring to the help of the head of the media only with the correction
dosages.

  • AT случае, когда человек с инвалидностью отказался от
    drug provision and gets cash for it
    compensation

he may start getting the required pills, capsules or
patches for free. I need to get a certificate from the local doctor.
free form about the need for expensive therapy
with indication of the drug, its dose and frequency of use for the seal
physician and medical institution, which must be provided in
Pension Fund. Preferential drug provision
recovers from the beginning of the following reference
of the month.

To obtain Fentanyl in a patch, the patient must:

  • Contact the pharmacy in person or fill out a power of attorney addressed to
    relative in a medical institution.
  • As before another therapy, a person is asked to complete
    informed consent to initiate therapy.
  • The patient is given instructions on the use of the skin.
    plaster.
  • Disability in cancer pathology should start
    make out from the moment of verification of the diagnosis and getting results
    histology. This will allow by the time chronic pain occurs.
    syndrome and its progression to take advantage of all the possibilities
    anti-pain therapy.
  • AT отсутствии возможностей получить накожный пластырь
    painkiller for free or buy for your own money, man
    morphine is offered in one of the dosage forms. Injection
    формы Morphineа назначаются и при невозможности обеспечить пациенту
    taking non-parenteral opioids. Injections are performed by SP or
    hospice workers in the patient’s residence.
  • About all cases of undesirable effects of drugs
    or incomplete pain suppression should inform your
    the therapist. He will be able to correct treatment, to replace the regime.
    treatment or dosage forms.
  • When switching from one opioid to another (due to inefficiency,
    side effects) the initial dosage of a new drug is chosen
    slightly below that shown in order to avoid the summation of doses and effects
    overdose.

Thus, adequate pain therapy for
cancer patients in the Russian Federation is not only possible, but also available.
Notобходимо лишь знать порядок действий и не терять драгоценное
time showing forethought.

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