How did you successfully quit opiates

Treatment of pain with medication

The basis for drug treatment of pain is how it is felt by the patient (i.e. how strong, where, when, for how long see above pain measurement). This pain should be eliminated or at least relieved as much as possible. To do this, the medication must be dosed appropriately and appropriately according to age and must be taken in good time - ideally according to a fixed schedule. In addition, attention must be paid to possible undesirable side effects of the medication.

There are also medicines for extra needs, for example in the case of suddenly worsening pain.

Important to know: The selection and dosage of painkillers (analgesics) are based on the severity, duration and other characteristics of the pain, as well as the individual condition of the patient.

The doctor usually orients himself to the generally accepted one Step-by-step scheme of pain treatment of the World Health Organization (WHO):

Fig. © kinderkrebsinfo.de

Treatment of mild pain

The treatment of pain perceived as weak is carried out according to WHO level I with a so-called non-opioid pain medication. In general, non-opioid pain medication inhibits the uptake of pain stimuli in the nerve tract. Details of their mechanisms of action are currently still being researched. Most non-opioids can be administered as tablets, juice, suppositories or intravenously (IV). Non-opioids, which are used in the treatment of pain in children and adolescents with cancer for example:

Paracetamol

Paracetamol is used regularly to treat pain in children and adolescents. The side effects of paracetamol are low when used properly.

Important to know: Paracetamol overdoses are the leading cause of liver failure in children. Since liver function is often impaired in children and adolescents with cancer, pain treatment with this drug should only be initiated and monitored by the responsible doctor.

Ibuprofen and diclofenac

These substances belong to the so-called non-steroidal anti-inflammatory drugs (NSAIDs) because, like glucocorticoid e, they are also used in the treatment of rheumatic pain. Children and adolescents with cancer in whom the number of blood platelets is low and / or kidney and liver function is impaired should not receive NSAIDs or only receive it in adapted doses. A common undesirable side effect of NSAIDs is stomach pain.

Metamizole

Metamizole is often combined with weak or strong opioids (see below). It is believed that in this way the amount of opioids and, consequently, their side effects can be minimized. Metamizole works particularly well against cramping abdominal pain. Important undesirable side effects are hypersensitivity reactions, allergies and, albeit rarely, bone marrow failure (agranulocytosis) and impaired circulatory function. Patients with an unstable circulation therefore do not receive metamizole for pain therapy.

Important to know: No acetylsalicylic acid (ASA) for children and adolescents with cancer! Pain treatment with acetylsalicylic acid (ASA) is generally not carried out in children because of the risk of triggering Reye's syndrome. In addition, ASA causes hemostasis to be disrupted for days in every person. Since many children with cancer can persistently have too few blood platelets even in the palliative setting due to previous chemotherapy, ASA should definitely not be used in them.

If the pain relief with non-opioids is not sufficient, treatment according to WHO level II, in some patients also immediately according to WHO level III (see picture) is displayed.

Treatment of moderate and severe pain with opioids and opiates

Opioids and opiates block the conduction of pain in the brain and spinal cord. Most of them can be swallowed, given through a special patch, or given intravenously. Well-known weak or strong opioids / opiates, with which there is already a lot of experience in the treatment of pain in children and adolescents with cancer for example Tramadol and morphine.

Dealing with unwanted side effects of opioids / opiates

The side effect profile of individual opioids / opiates can vary greatly from patient to patient. Rarely and mainly after intravenous (IV) administration of strong opioids / opiates, low blood pressure, itching, breathing disorders (respiratory depression) and, in allergy sufferers, asthma attacks occur. Psychological changes (e.g. high spirits (euphoria), confusion, nightmares or hallucinations), dry mouth and sweating do not often occur in children as part of opioid pain therapy. However, if these side effects occur, the following is possible: reduce the current opioid dose, give it in a different form, or change the opioid (for example to methadone or hydromorphone). Unwanted opioid side effects that are more common include:

  • constipation (Constipation): Most common undesirable side effect of opioid treatment. The regular administration of laxatives (for example in suppository form) helps to prevent or treat constipation.
  • Nausea and vomiting (Nausea): Occur mainly in the early days of pain therapy with opioids. For older children (> 12 years) there is the possibility of preventing nausea with certain medications (antiemetics) that are administered promptly with the opioid.
  • Urinary retention: Rarely occurs with very young children, but can cause panic in those affected. Soothing words, a wet washcloth on the skin over the urinary bladder region or the sound of a running tap often help. If these measures are unsuccessful, the urinary retention in adolescents can be treated with medication (for example with distigmine bromide) or, especially in younger children, with single-use catheterization.
  • Opioid fatigue (Sedation): Usually occurs at the beginning, but sometimes also during long-term therapy or when dose adjustments are made. The risk of such sedation is increased in patients with impaired kidney and / or liver function. They prefer other strong opioids (such as buprenorphine) to morphine.
  • Increased sensitivity to pain (Hyperalgesia): May occur in some patients after some time on morphine treatment. With each increase in the opioid dose, those affected report more pain or become extremely sensitive to touch. In this case, a reduction in the opioid dose, a different form of administration or a change of opioid is indicated.

Physical habituation to opioids / opiates

Many parents, older children and adolescents, and sometimes members of the treatment team, shy away from treatment with morphine because they are concerned that it will make the patient addicted to drugs. However, this fear is unfounded.

Good to know: Morphine preparations can successfully relieve pain in children and adolescents with cancer and usually even eliminate it completely. The fear of developing addiction is unfounded because the body of pain patients reacts very differently to opioids than in people who do not suffer from pain: When used properly against pain, they do not generate intoxication and therefore also do not create the urge to abuse substances.

Source: Parents brochure "Less pain in cancer"

After a certain period of treatment with opioids / opiates, however, there may be temporary physical habituation. As a result, certain of their side effects, such as nausea, decrease, but not their pain-relieving effect. With professional treatment, this remains the same for the entire duration of the treatment.

However, because of the physical habituation, opioid treatment must not be stopped abruptly. The daily gifts are gradually reduced, provided that the cause of the pain has been eliminated. This way, complications like diarrhea and shakiness do not occur.

Treatment with supportive drugs (adjuvants)

In connection with their pain, children and adolescents with cancer in the palliative phase can also develop other complaints such as insomnia and anxiety, or very special pain syndromes (e.g. bone pain, neurogenic pain, headache). With them, certain drugs can contribute to the effect of the pain relievers. These so-called adjuvants include, for example:

  • Mood enhancer (tricyclic antidepressants): Have a dampening effect on neurogenic pain (for example after chemotherapy with vincristine or if the tumor continues to grow in the surrounding tissue)
  • Sedatives (Sedatives, hypnotics): Effect on severe sleep disorders and seizures
  • Psychiatric drugs (Neuroleptics): Help with severe nausea and vomiting
  • Anti-epileptic drugs (Anticonvulsants): not only prevent seizures, but also work against sudden, severe nerve pain
  • Steroid hormones (Glucocorticoid e): Reduce nausea and vomiting, as well as pain caused by the pressure of a mass on the surrounding tissue (for example headache from a large brain tumor or bone pain from aggressive tumor growth in the bone tissue).

Important to know: Pain is a useful warning sign of complications from pain management, the underlying disease and its previous treatments, as well as other problems such as infections. When painkillers are used, pain loses its warning function. You should therefore pay particular attention to side effects.

Picture of a patient

Pain map

The German Children's Pain Center explains various scales for perceiving and assessing pain on an overview page. Painkillers are also listed. This page is available as a download and for doctors for a small fee as a pocket version