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  • Content
  • CPCRE
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  • Content
    • Introduction
    • Responses to Patient FAQs
    • Treatment tree
      • Get Started
      • Mild to Moderate Pain
      • Moderate to Severe Pain
      • Breakthrough Pain
    • Precautions When Using Opioids
    • Difficult Pain Control
    • Equianalgesic Dosing
    • Incident Pain
    • Mode of Action
    • Morphine Myths and Facts
    • Route of Delivery
  • Opioids
    • Choosing an Opioid
    • Opioid Comparative Information Table
    • Opioid Formulation Table
    • Opioids in Special Populations
    • Opioids to Avoid
  • Individual Opioids
    • Buprenorphine
    • Codeine
    • Fentanyl
    • Hydromorphone
    • Methadone
    • Morphine
    • Oxycodone
    • Tramadol
    • Tapentadol

Precautions When Using Opioids

Gastrointestinal#

Use opioids with caution in patients with ileus; consider parenteral route of administration as oral absorption may be minimal.. Use with caution after biliary surgery or in patients with biliary colic; opioids may cause spasm of sphincter of Oddi.

Respiratory#

Use opioids with extreme caution in patients with respiratory depression, severe obstructive airways disease, at risk of upper airways obstruction (e.g. sleep apnoea), or decreased respiratory reserve as they may depress respiration, decrease the cough reflex and dry secretions. However, morphine can be used to manage or control some forms of dyspnoea.

Renal#

Because active/toxic metabolites accumulate in renal impairment, avoid use of codeine, dextropropoxyphene and pethidine; use hydromorphone, morphine and tramadol with caution. Adjust dose or use an alternative opioid, such as fentanyl or buprenorphine.

Hepatic#

Dose adjustment may be required in hepatic impairment.Avoid oxycodone/naloxone combination drugs (Targin) as naloxone will not be metabolised.

Elderly#

Opioid dose requirement decreases progressively with age. There is an increased risk of adverse effects including cognitive impairment, sedation, respiratory depression and falls. Use a lower initial dose and titrate to effect.

Children#

Opioid use in children is usually initiated or recommended by specialists.

Neonates and children up to approximately 12 months are more susceptible to respiratory depression associated with opioid use. Start with a low dose and titrate to effect.

Pregnancy#

Opioid analgesics may cause respiratory depression in the newborn; withdrawal effects may occur in neonates of dependent mothers.

Breastfeeding#

Safe to use occasional doses of opioids but avoid codeine. Use repeated doses with caution, especially if infant is premature or <4 weeks old; monitor infant for sedation and other adverse effects.

Uncorrected endocrine abnormalities#

Hypothyroidism, adrenocortical insufficiency, alcoholism, myasthenia gravis, CNS depression—careful dose titration required.

Epilepsy or a recognised risk for seizure#

e.g. head injury, metabolic disorders, alcohol and drug withdrawal, CNS infections—may increase risk of seizure.

Hypotension, shock#

Reduced blood volume increases hypotensive risk and increases risk of respiratory depression; also impairs IM/SC absorption; careful titration of opioid dose required.

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  • Gastrointestinal
  • Respiratory
  • Renal
  • Hepatic
  • Elderly
  • Children
  • Pregnancy
  • Breastfeeding
  • Uncorrected endocrine abnormalities
  • Epilepsy or a recognised risk for seizure
  • Hypotension, shock
Copyright ©2021
Built by ACRRM on behalf of CPCRE

    Welcome

    Welcome to the GP Pain Help App, to help GPs manage cancer pain in their patients.

    General principles

    Opioids are the only pharmacological class of drug with the ability to control severe pain.

    Use oral route first line where possible.

    Dose regularly with controlled-release (CR) preparations, with as required (prn) immediate-release (IR) doses (1/6 daily dose) to assess analgesic requirements.

    Titrate dose against effect and toxicity – consider switching to another class of opioid if toxicity becomes dose-limiting.

    Disclaimer

    The information within this app is presented by the Centre for Palliative Care Research and Education (CPCRE) for the purpose of disseminating health information free of charge and for the benefit of the healthcare professional.

    While CPCRE has exercised due care in ensuring the accuracy of the material herein, the information provided should be treated as a guide only to appropriate practice, to be followed subject to the clinician’s judgment and the patient’s preference in each individual case.

    CPCRE does not accept any liability for any injury, loss or damage incurred by use of or reliance on the information contained herein.

    Acknowledgement

    CPCRE acknowledges the work of Professor Janet Hardy, Associate Professor Phillip Good and the Australian College of Rural and Remote Medicine (ACRRM) in development of this pain aid for GPs.