American journal of hospital pharmacy
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The use of spinally administered opioids to manage pain is discussed. Central action on opioid receptors of the substantia gelatinosa allows opioids to be administered spinally for pain originating anywhere inferior to the cranial nerves. Spinal opioids are most commonly administered for intractable midline sacral and perineal pain. ⋯ Adjuvant drugs used with spinal opioids include systemically administered analgesics, antidepressants, corticosteroids, and spinal local anesthetics. The administration of spinal opioids with systemic opioids or other CNS depressants may result in excessive sedation, respiratory depression, nausea, vomiting, constipation, pruritus, and other adverse effects. Spinally administered opioids can be used to manage severe chronic pain effectively, safely, and comfortably.
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The fiscal impact and acceptability of implementing a syringe-pump infusion system at a 900-bed university teaching hospital where the minibag system has been in use is reported. Researchers selected three models of syringe pumps for evaluation: the Bard Harvard Mini-Infuser 150XL, the Becton Dickinson 360 Infuser, and the Strato Stratofuse System. Each pump was evaluated for three weeks on a medical-surgical unit and a hematology-oncology unit. ⋯ The time required to prepare syringes did not differ substantially among syringe-pump models. It was estimated that using any of the evaluated pumps in place of the minibag system would save $126,500 during the three-year period 1988-91, primarily because of differences in the cost of disposable items. The syringe-pump infusion system is an acceptable and cost-effective alternative to the minibag system.
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The pathogenesis of cancer pain, the incidence of pain associated with specific types of malignant tumors, and the nature of acute and chronic pain are discussed, and alternative delivery systems for pain management are described. More than 80% of cancer patients with advanced metastatic disease suffer moderate to severe pain. Most cancer pain is caused by direct tumor infiltration; approximately 20% of cancer pain may be attributed to the effects of surgery, radio-therapy, or chemotherapy. ⋯ The duration and onset of analgesia depend on the lipophilicity of the agent used. Because pain is the most common complaint of the patient with cancer, clinicians should be aware of the range of pharmacologic and nonpharmacologic analgesic modalities available to them. Familiarity with newer modalities and delivery routes, such as spinal administration of opiate analgesics, is recommended.
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The use of infusion devices for epidural or intrathecal administration of spinal opioids is described. The risks of infection and mechanical catheter complications, the need for escalating doses, reservoir volume, drug stability, and cost are practical considerations associated with use of both external and internal infusion systems. Use of patient criteria to identify suitable candidates for intraspinal administration of pain medication helps ensure successful management. ⋯ A programmable implanted pump is available. Two advantages of continuous epidural or intrathecal infusion are (1) the peaks and valleys of pain relief with bolus injections are eliminated and (2) the need for multiple injections is reduced. Patient-controlled analgesia (PCA) pumps enhance the efficacy of continuous infusions by allowing the patient to administer bolus doses to control acute pain.
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The mechanism of action of opioids and clinically relevant differences among the opioid analgesics are described. Both endorphins (endogenous morphine-like substances) and exogenous opioids (opium alkaloids and their derivatives) bind to opioid receptors in the human central nervous system to provide analgesia and other effects. Some drugs, such as morphine, are true agonists, i.e., they bind to and activate receptors. ⋯ This fact mediates against the use of partial agonists and agonist-antagonists in cancer patients who have chronic pain that may increase as the disease progresses. Three major factors that should be considered when a drug is selected for clinical use are (1) relative affinities for the different opioid receptor types, (2) pharmacokinetic characteristics that influence onset and duration of action, and (3) whether the opioids are strong or weak. For treatment of cancer pain, drugs with long durations of action are preferable.(ABSTRACT TRUNCATED AT 250 WORDS)