July 1997 Bulletin
Don't fear opiates to manage pain
Physicians urged to expand knowledge of analgesics
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
- 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
- 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
- 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
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
- 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.