Palliative care – 7 – Pain 5

Palliative Care PART – 7

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question:  Last time we covered some important aspects of pain management related to opioid usage.               1. Fear of sedation. Rarely an issue. Initially sedation related to better pain control, in some patients. 2. Misconception: morphine prescription means end is near. Explained how it is used in many cases for short term pain control, in cancer as well as many non cancer conditions. 3. Opioids other than morphine. Fentanyl discussed.

These are very important practical points we discussed. What about other opioids?

Ans: Sure. But before we go to other opioids, some other important points related to fentanyl patch. We saw its limitations last time. Advantages include: 1. Useful for those who are on high doses of oral morphine. To reduce that requirement and provide smoother pain control. 2. Very useful for those who cannot swallow medicines such as due to cancer or altered mental status or those with absorption issues. Or those who do not have adequate help to deliver timely oral morphine every time patient has pain. 3. Some studies suggest that fentanyl causes less constipation compared with oral morphine.

Que: Thank you for highlighting the good side of fentanyl patch too! What about the more commonly used opioids in India, such as Tramadol and Tapentadol.

Ans: Yes thank you for bringing this up. These medicines are used less commonly in western countries due to clear lack of benefit over morphine. Hence most articles, books, courses on pain control talk about morphine, but not these two. Limited available literature does not provide good formal comparison for these two against morphine.

Tramadol and Tapentadolare mixed mechanism drugs. Unlike morphine which is a pure mu receptor agonist.  We can talk about our own experience however using mainly Tramadol. Many practitioners in India, at least in Gujarat, are a lot more comfortable with prescribing Tramadol. Perhaps because legal restrictions are far less, with many more pharmacies also supplying it. We see this very commonly for cancer pain, as well as for non cancer pain. Tramadol is frequently used in Gujarat as next level after paracetamol and NSAIDs. It is used alone or in combination with paracetamol, as fixed dose combination-  a very widely used brand of combination is available. Injectable use of tramadol is also very common in hospitals, including both subcutaneous and intravenous. Injectable is frequently given with antiemetic, as there is a fairly high incidence of vomiting otherwise. Some patients also complaint of marked giddiness with oral or injectable both. However a number of patients have good pain relief, and due to ease of availability, it becomes a favored drug.

In our own experience however, for cancer pain of course, morphine works where tramadol does not. Reverse is true in very few patients. Morphine also allows much better titration of dosage, and frequency of dosing, as per pain requirement. For example, there are many patients whose pain control is fairly good, but lasts only for about 2-4 hours after one dose. Morphine can be repeated every 4 hours in such patients, but tramadol cannot. Same way morphine dose can be increased from 5 mg to 100 mg per dose, with so many levels of dosing in between. Not with tramadol.

Our personal experience with use of Tapentadol is limited, but seems same as tramadol.

Que: Thank you. I also use a lot of tramadol with or without paracetamol combination for many of my cancer patients, and some other patients too. What about other available patch in Indian market i.e. Buprenorphine? It is also easier to use i.e. every 7 days.

Ans: Yes Buprenorphine requires change every 7 days compared with fentanyl. And it comes in multiple strengths. Studies in cancer pain and experience are limited. But this certainly is an option. It is fairly expensive however. Similarly in India, codeine is an option. Availability is variable. But it has been used alone or in fixed combination with paracetamol or NSAID. Once again, compared to morphine, there is less experience for cancer pain, and less ability to titrate dose. Also, analgesic potency seems less than morphine. But similar to tramadol, it is favored due to less restrictions on use and more pharmacies willing to supply.Morphine is also a safer option compared with all these other opioids in terms of safety in patients with liver or kidney function impairment. However we do understand that options other than morphine are more easily available in towns, and even in cities. And do not require triplicate prescriptions, can be prescribed by non oncologists easily. But do remember that if patients are not having adequate pain relief with non morphine options, you can refer them to palliative care centers, pain specialists or oncologists. Rather than compromising on pain control. March 15,2021. 

Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedahbad. drchiragashah@gmail.com