Upload
stephany-preston
View
219
Download
0
Tags:
Embed Size (px)
Citation preview
Pre-reading about Opioid Analgesia for Children
Royal Children’s Hospital
Melbourne Australia
The use of opium
• Opium was first discovered in pre-biblical times; derived from the opium poppy
• Opium was widely used from the middle ages in a medicine known as “tincture of opium” or Laudanum
Children's Pain Management Service, RCH, Melbourne
What are opioids?
• All drugs with morphine-like actions are described as opioids
• Opioids were originally derived from the opium poppy (papaver somniferum) which has 25 alkaloids
• Only two of these alkaloids have any analgesic action: morphine and codeine
Children's Pain Management Service, RCH, Melbourne
GlaxoSmithKline supplies ~25% of the world's medicinal opiate needs from opium poppies grown by farmers in Tasmania
Children's Pain Management Service, RCH, Melbourne
Opioid or Narcotic?
Opioid: natural, semi-synthetic and synthetic drugs that relieve pain by binding to opioid receptors in the nervous system
Narcotic: obsolete term for opioid, because governments and media use the term loosely to refer to a variety of substances of potential abuse including opioids, cocaine and other substances
Children's Pain Management Service, RCH, Melbourne
Opiate or Opioid?Opiate:
term used to refer to drugs derived from the opium poppy, for example, morphine (thus excluding synthetic opioids such as fentanyl)
Opioid:refers to any substance with morphine-like activity including natural, semi-synthetic and synthetic opioids
Children's Pain Management Service, RCH, Melbourne
How morphine was named
• In 1805, a German pharmacist (Serturner) isolated an opium alkaloid
• He named it morphine (after Morpheus, the Greek god of sleep)
Children's Pain Management Service, RCH, Melbourne
How do opioids work?
• All opioids bind to opioid receptors • Opioid receptors are located in the:• peripheral nervous system• spinal cord• brain
• When opioids bind to these receptors they affect the transmission of pain signals to the brain
Children's Pain Management Service, RCH, Melbourne
Opioid receptors
There are three main types of opioid receptors:
• mu ()• delta ()• kappa ()
These receptors have multiple actions
Children's Pain Management Service, RCH, Melbourne
Mu() opioid receptors
• The mu receptors are associated with:• analgesia• side effects
• Mu receptors are subtyped: mu-1 & mu-2
Children's Pain Management Service, RCH, Melbourne
Action at the mu() receptor
• Mu-1 receptor is responsible for analgesia
• Mu-2 receptor is responsible for the opioid side-effects:• respiratory depression• cardiovascular depression• decreased gastrointestinal motility • sedation• euphoria• urinary retention
Children's Pain Management Service, RCH, Melbourne
Mu-1 specific opioids do not exist• The opioid action of all known
natural and synthetic opioids at mu receptors is non-specific
• No opioid has yet been found or developed that acts only on the mu-1 receptor
Children's Pain Management Service, RCH, Melbourne
Opioid receptor antagonist• Naloxone (NarcanTM) is a pure opioid
receptor antagonist• Naloxone displaces opioids bound to
opioid receptors• The duration of action of naloxone
is 30-60 minutes• Thus naloxone may wear off before
a longer acting opioid and symptoms of opioid toxicity may reappear
Children's Pain Management Service, RCH, Melbourne
Indications for opioids
• Pain
• Intractable diarrhoea• Cough• Air hunger (end-stage respiratory
failure)
Children's Pain Management Service, RCH, Melbourne
Contraindications to opioids
The following are not absolute contraindications,
as opioids may be used in small titrated doses:
• depressed conscious state (relative)
• head injury (relative)• respiratory insufficiency (relative)
Children's Pain Management Service, RCH, Melbourne
Precautions
Neonates:• lower doses may be required• decreased clearance of opioids and
opioid metabolites
Children's Pain Management Service, RCH, Melbourne
Side effects of opioids
• Opioid side effects occur regardless of which opioid is used
• Side effects are usually dose-related
Children's Pain Management Service, RCH, Melbourne
Side effects of opioids
• respiratory depression
• sedation• euphoria • pinpoint pupils• itch • muscle rigidity
• bradycardia (with high doses)
• vasodilation • hypotension • urinary retention• nausea & vomiting• delayed gastric
emptying• constipation
Children's Pain Management Service, RCH, Melbourne
Respiratory depression
• Respiratory depression from opioids is due to the combination of sedation, decreased tidal volume, reduced respiratory rate and a drop in oxygen saturation
• This results in hypoxia and raised carbon dioxide levels, which leads to further sedation and further respiratory depression
Children's Pain Management Service, RCH, Melbourne
Different opioid drugsMorphine:
• pure opioid• powerful mu agonist• varied formulations (oral, IV/IM/SC)
• oral immediate release eg Morphine mixture/tabs, KapanolTM
• oral sustained release eg MS ContinTM
• the metabolites are M3G and M6G• morphine 3 glucuronide & morphine 6 glucuronide
Children's Pain Management Service, RCH, Melbourne
Different opioid drugs
Codeine:• pure opioid• mu agonist• prodrug (converts to another form) • converts to morphine• 7-10% of some population groups are
unable to convert codeine to morphine, thus get no analgesia effect while others are rapid converters and become sedated.
Children's Pain Management Service, RCH, Melbourne
Different opioid drugs
Pethidine: (rarely used at RCH)
• synthetic opioid• mu agonist• metabolite is nor-pethidine• pethidine infusions should be
avoided due to the concerns of nor-pethidine toxicity
Children's Pain Management Service, RCH, Melbourne
Different opioid drugs
Fentanyl:
• synthetic opioid• mu agonist • structurally similar to pethidine• short acting, but a lipophilic (fat
soluble) drug which may result in accumulation
• no metabolitesChildren's Pain Management
Service, RCH, Melbourne
Different opioid drugs
Hydromorphone (DilaudidTM):
• synthetic opioid• related to oxycodone and
hydrocodone• varied formulations (oral, IV/IM/SC,
epidural)• the metabolites are H3G and H6G
• hydromorphone 3 glucuronide & hydromorphone 6 glucuronide
Children's Pain Management Service, RCH, Melbourne
Different opioid drugs
Oxycodone:
• synthetic opioid• related to hydrocodone and
hydromorphone
• similar strength to oral morphine• sustained release version available• OxycontinTM
Children's Pain Management Service, RCH, Melbourne
Different opioid drugs
Dextropropoxyphene:• synthetic opioid• weak mu agonist• preparations often mixed with
other analgesics• eg combined with paracetamol as DigesicTM
Children's Pain Management Service, RCH, Melbourne
Different opioid drugs
Methadone:• synthetic opioid• strong mu agonist• very long acting opioid• useful for neuropathic pain• no metabolites
Children's Pain Management Service, RCH, Melbourne
Different opioid drugs
Tramadol:
• not a true opioid • has opioid and non-opioid
properties• non-opioid effects are via nor-
adrenaline and serotonin pathways• active metabolite (M1) has mu
receptor affinity
Children's Pain Management Service, RCH, Melbourne
Misbeliefs about opioids and children • ‘Children are more sensitive to opioids’• ‘Infants and neonates do not feel pain’• ‘Pain is character building’• ‘Children have little requirements for
opioids’• ‘Children can be easily overdosed’• ‘The use of opioids leads to addiction’
Children's Pain Management Service, RCH, Melbourne
Misunderstanding of definitions
• Confusion about the definitions of addiction, tolerance, withdrawal and the implications for patients are the main reason that opioids are under utilised
Children's Pain Management Service, RCH, Melbourne
Definitions
• Addiction: psychological dependence with compulsive drug use, and craving for opioids for effects other than pain relief
• Tolerance: when increased doses of a drug is needed to produce the same pharmacological effect
Children's Pain Management Service, RCH, Melbourne
Definitions
• Withdrawal: a cluster of physiological signs and symptoms, which occur after sudden ceasing of some drugs
• Dependency: when sudden absence of an opioid produces physical withdrawal syndrome
Children's Pain Management Service, RCH, Melbourne
Fear of addiction• Fear of creating addiction in patients
contributes to the under use of opioid analgesics (Ferrell BR et al, J Pain & Sympt Manage, 1992)
• The risk of addiction for patients having opioids for medical reasons is extremely low
• Tolerance to an opioid does not mean the patient has an addiction
Children's Pain Management Service, RCH, Melbourne
Caring for children receiving opioids• Accurate documentation• Correct dose of opioid• Correct and safe delivery of opioid• Observation of vital signs• Minimal side effects • Documented pain scores • Adequate analgesia achieved
Children's Pain Management Service, RCH, Melbourne
Caring for children receiving opioids• Monitoring
sedation score pain score respiratory effort, rate, depth oxygen saturation heart rate
Children's Pain Management Service, RCH, Melbourne
Combining opioids• It is not good practice to administer more
than one opioid at a time, as this increases the risk of side effects
• At RCH we do not administer morphine and codeine together
• An exception is when long-acting and short-acting formulations of the same opioid are administered for optimal analgesia in patients with severe pain eg MS Contin & morphine mixture OR Oxycontin & oxycodone
Children's Pain Management Service, RCH, Melbourne
Optimising opioid analgesia
• The child needs to be comfortable• The child needs to be able to
breathe deeply/cough without pain• The child needs to be able to
mobilise freely without being limited by pain
Children's Pain Management Service, RCH, Melbourne
Optimising opioid analgesia• Pre-emptive pain management is
important• Treat side effects early and adequately• Adjunctive analgesia may be required• Children should not be sedated• Believe the child’s pain assessment • Act on assessment
Children's Pain Management Service, RCH, Melbourne
Children's Pain Management Service• The Children's Pain Management
Service supervises most patients with opioid infusions at Royal Children's Hospital
• CPMS can be contacted at all times on pager 5773
Children's Pain Management Service, RCH, Melbourne
Finally…
Optimal pain management is the right of all patients and the responsibility of all health professionals
Children's Pain Management Service, RCH, Melbourne