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thesis cover page unsw One method involves adjustment of the maintenance dose based on the total 24-hour rescue dose requirement. Alternatively, utilizing dose escalation, doses could be increased by 50% to 100% or 30% to 50% of the current dose, for those in severe and moderate pain, respectively. Once pain relief is achieved, and if treatment is necessary for more than a few days, conversion to a controlled-release or long-acting opioid should be made with an equal amount of agent. Several sustained-release products are available containing morphine, oxycodone, and fentanyl. Some clinicians will reduce the total daily dose of the longacting dosage form by 25% when initiating a sustained-release product to reduce the likelihood of oversedation. The dose of a pure agonist is limited only by tolerability to side effects. Tolerance might develop to analgesic effects, necessitating increasing doses to achieve the same level of pain relief. Physical dependence will occur with the long-term use of opioids. However, addiction or psychological dependence is unlikely in legitimate pain patients unless there are predisposing risk factors. Pain patients who are undertreated might appear to be drug seeking (pseudoaddiction). However, effective pain management resolves the behaviors. When opioids are used for chronic pain, use of informed consent for chronic opioid therapy, medication management agreements, or pain contracts might be appropriate to monitor the use (prescribing and dispensing) of controlled substances. Opioids are administered by a variety of routes, including oral (tablet and liquid), sublingual, rectal, transdermal, transmucosal, iv, subcutaneous, and intraspinal. Although the oral and transdermal routes are most common, the method of administration is based on patient needs (severity of pain) and characteristics (swallowing difficulty and preference). Oral opioids have an onset of effect of 45 minutes, so iv or subcutaneous administration might be preferred if more rapid relief is desired. Intramuscular (im) injections are not recommended because of pain at the injection site and wide fluctuations in drug absorption and peak plasma concentrations achieved. More invasive routes of administration such as pca and intraspinal (epidural and intrathecal) are primarily used postoperatively but might also be used in refractory chronic pain situations. Pca delivers a selfadministered dose via an infusion pump with a preprogrammed dose, minimum dosing interval, and a maximum hourly dose. Morphine, fentanyl, and hydromorphone are commonly administered via pca pumps by the iv route but less frequently by the subcutaneous or epidural route. Epidural analgesia is frequently used for lower extremity procedures and pain (eg, knee surgery, labor pain, and some abdominal procedures). Intermittent bolus or continuous infusion of preservative-free opioids (morphine, hydromorphone, or fentanyl) and local anesthetics (bupivacaine) might be used for epidural analgesia. Opiates given by this route might cause pruritus that is relieved by naloxone. Adverse effects including respiratory depression, hypotension, and urinary retention might occur. When epidural routes are used in narcotic-dependent patients, systemic analgesics must also be used to prevent withdrawal because the opioid is not absorbed and remains in the epidural space. Doses of opioids used in epidural analgesia are 10  times less than iv doses, and intrathecal doses are 10 times less than epidural doses (ie, 10 mg of iv morphine is equivalent to 1 mg epidural morphine and 0. 1 mg of intrathecally administered morphine). 38 combination analgesics  combinations of opioids and nonopioids often result in enhanced analgesia and lower dose of each. Combination analgesics are frequently used in moderate pain. However, in severe pain, the nonopioid component reaches maximum dosage, and thus the usefulness of nonopioids in this situation is limited. Additionally, the combination products are short acting and often not suitable for chronic therapy. Single agents offer greater dosing flexibility than combination products.

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