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P A I N
M A N A G E M E N T
Benefits and drawbacks of opioids
It's true, opioids are potent analgesics that can be titrated within a
wide range. So we've been trained to titrate opioids until we achieve
comfort in the patient. But the more I do this, the more I think opioids
don't have limitless titration. Most patients would rather have pain
than nausea and vomiting. And nausea and vomiting are very common
in patients receiving opioids, occurring about 40% of the time.
Respiratory depression is also a very common side effect, posing a big
risk in patients with (often undiagnosed) sleep apnea. Other issues
associated with opioids:
• GI side effects (constipation);
• sedation, confusion, mental status changes and intracranial pressure
concerns; and
• hemodynamic effects.
Although the United States contributes about 4% of the world's population, it uses about 90% of the world's opioids. (See page 8 for the
latest on Vicodin, the most prescribed drug overall in America.)
Because of that demand, abuse and diversion should be real concerns
for you.
Your non-opioid arsenal
Opioids are great for nociceptive pain, but pain is multifactorial, with
nociceptive, visceral, neuropathic, inflammatory and spasmodic components. A multimodal regimen that targets each of these factors (or
just the relevant ones) can eliminate opioids or render them to supplemental treatment.
Multimodal means starting with 1 intervention (for example, acetaminophen), and adding medications or interventions subsequently in
response to increased pain intensity. Employ different medications —
including steroids and local anesthetics — with varied mechanisms of
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