«opwtee ortontMlon or pain-m Ions ily

by the ladder by mouth-*^ by the cl ock -for the individual-attention to detaik. hsxfl.« (wttwt feytoMndwot ftpm the supply ot other!

-i" (axftSBMSUiaWHWffliBMte. WsMna brcakthrouoh pain, which would result In dese-escafoBrm and peychii; niiridrtiwiinjj

situation of the Bat lent avoWlns eiandarddesina sr—/ \ Jmx? an optimal ilMWl

"1 fieiamejn rak^yeRef [ raw for the» psfleni

Figure IV-2. The WHO global perspectives and goals in chronic pain therapy continuous and therapeutic plasma levels of analgesics must be maintained. This only can be achieved when the drug is given regularly at correct intervals according to the pharmacokinetic and pharmacodynamic profile of the drug:

5. Analgesia for continuous pain should be prescribed on a regular basis, not as required (pro re nata).

6. It should be explained to the patient with chronic cancer pain that pain control medication must be taken regularly to gain optimal results.

In such patients, treatment should start immediately in order to achieve rapidly sufficient analgesia and potent opioids should be administered from the start.

As it is the case with all modalities in opioid therapy, rigid dosing has to be rejected in chronic pain therapy. Dosages have to be increased to a point of sufficient pain relief. Such dogma especially is necessary in the therapy of chronic pain because a continuous analgesic effect is only possible by continuous occupation of the opioid receptor, a principle. This can be achieved only by constant plasma level using a controlled release formulation.

In summary, when initiating opioid therapy the following factors have to be considered:

• Severity of pain

• Setting in which the regimen will be started

• Whether patient is opioid-naive

• Prior medication exposure and experience Then start titration of the opioid keeping in mind:

1. Start at lowest acceptable dose

2. Adjust dose for pain relief with acceptable side effects

3. Use a titration rate depending on opioid half-life

Table IV-1. Classification of opioid analgesics into agonists, partial agonists, agonist/antagonists and antagonists













Dextropropoxyphene Diamorphine (heroin) Tramadol Phenazocine

Antagonists Naloxone Naltrexone Nalmefene


Partial agonists Buprenorphine Meptazinol

Butorphanol Nalbuphine Dezocine



4. There is no analgesic ceiling to single-entity opioid agonists

5. Use a maximum dose of the opioid in combination with a nonopioid within dose limits (e.g., acetaminophen 4g/d).

When administering opioids for the alleviation of pain the following principles have to be considered.

The group of agonists (e.g., codeine, morphine, meperidine, fentanyl) has to be strictly separated from the group of the partial agonists (buprenorphine, meptazinol) and from the mixed agonist/antagonists (nalbuphine, pentazocine, butorphanol, dezocine; Table IV-1).

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