July 1997 Bulletin

Don't fear opiates to manage pain

Physicians urged to expand knowledge of analgesics

Physicians must expand their knowledge of the types and uses of the opiates to improve the management of their patients' pain, says Peter Koo, PharmD, associate clinical professor of pharmacy specializing in pain management, University of California, San Francisco.

Koo says physicians are reluctant to use opiates because their medical training stressed caution and fear. The result is an increasing perception that physicians are not doing enough to manage their patients' pain when it is indicated. Koo reviewed a number of problems in pain management, including:

• Fear that opiates will cause dependence and addiction. Many physicians are not aware that the two are not synonymous. Dependency is a physiologic need; addiction is both psychological and physiologic. In reality, few patients become addicted because of the clinically indicated use of analgesics for an appropriate duration. It's the recreational use that most often causes addiction.
• Respiratory depression. If the dosage is too high or the opiate is not selected carefully the patient can suffer respiratory depression. An accurate opiate assessment or presurgical history is essential. Frequent dose adjustments and assessment also can minimize this side effect.
• Emesis. Vomiting, which occurs in about 16 percent of patients who receive morphine, can be prevented with judicious use of antiemetics. The less-nauseating opiates are Hydromorphone, Meperidine, Methadone or Fentanyl. Some surgeons use only one or two opiates, but they should open their repertoire of analgesics.
• Mental confusion. The elderly are more sensitive to the side effects of morphine. If the patient becomes forgetful, switching to an alternate opiate or an alternate delivery mechanism such as oral instead of injection can reduce this effect.
• Postoperative Ileus. Start a bowel regime early. Stool softeners don't work well alone because narcotics slow bowel propulsion. Use a stimulative laxative such as Bisacody or Senna or, in severe cases, Naloxone by mouth.
• Changing to an oral analgesic from an injectable analgesic. Allowing an overlap in the use of the patient control analgesic device to prevent "break through" of pain can improve this transition.
• Professional responsibility vs. potential liability. Physicians must exercise care in pain management because they can be held accountable if a patient is harmed from an overdose of opiates or if a patient has to endure agonizing pain caused by insufficient analgesics.
• Demanding patients. Patients may demand more and more opiates because the treatment is inadequate. Physicians also may have to deal with demanding patients when close monitoring is required if opiates are used for an extended period.
• Side effects. All opiates, with few exceptions, have side effects. Physicians must learn how to deal with the side effects.

Koo stresses the need for a presurgical evaluation to determine a patient's requirements for both anesthesia and postoperative pain management. To improve pain management, Koo advises physicians to:

• Know their limitations and know the constraints, such as the demands of having to deal with prolonged pharmacological pain management requirements.
• Learn how to identify patients who need additional guidance and control with pharmacological pain management. A pain management clinical pharmacist can oversee all the pain medication needed by a patient in collaboration with the physician and case managers. This approach can expand the physician's practice and capability and enhance patient satisfaction.
• Establish good communications between patient and caregiver.
• Give priority to pain and pharmacologic management.
• Anticipate pain and treat it aggressively. It's better to prevent pain than to chase it.