American journal of hospital pharmacy
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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)
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The osmolalities of pediatric i.v. admixtures were measured to identify drug concentrations in selected vehicles that would conserve fluid while maintaining osmolality values of 400 mOsm/kg or less. Test solutions were prepared by diluting appropriate volumes of freshly reconstituted powdered drug products or commercially diluted drug products with 5% dextrose injection, 0.9% sodium chloride injection, or both to provide 5 mL of each admixture at desired drug concentrations. To reduce their osmolalities, trimethoprim-sulfamethoxazole and ampicillin sodium were also diluted in 0.45% sodium chloride injection; ticarcillin disodium was diluted only in 0.45% sodium chloride injection. ⋯ Selected concentrations of the latter two drugs and ticarcillin disodium in 0.45% sodium chloride injection resulted in acceptable osmolalities. For most drugs diluted to the same concentration in 5% dextrose injection and 0.9% sodium chloride injection, osmolalities were lower in the dextrose solutions. Selection of an appropriate vehicle and drug concentration can control the osmolality of i.v. admixtures when the volume of fluid must be minimized, as for pediatric patients.
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The results of a spring 1987 survey of hospital pharmacy services in seven states of the Great Lakes region are reported. The study group (n = 1087) comprised all hospitals in seven states that employed at least one full-time or part-time pharmacist and that had 50 or more licensed beds. The survey had a 63% response rate (681 usable responses). ⋯ Workload and pharmacist staffing data for the inpatient clinical pharmacy services varied widely. Eleven of these services were expected to undergo a positive net growth, while one service, provision of admission medication histories, was expected to decline. An extensive survey of hospital pharmacy services in the Great Lakes region showed that the provision and scope of many services were related to hospital size, hospital teaching affiliation, and the education of the pharmacy director.