The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [343]
Opioids approved for oral transmucosal administration
Oral transmucosal fentanyl citrate (Actiq)
Licensed for the management of breakthrough pain in patients who are already on an established maintenance dose of opioid for cancer pain, oral transmucosal fentanyl citrate (OTFC) is a lozenge which is rubbed against the oral mucosa on the side of the cheek which leads to the lozenge being dissolved by the saliva. The advantage of OTFC is its fast onset via the buccal mucosa (5–15 minutes) and its short duration (up to 2 hours). It is available in a range of doses (200–1600 μg) but there is no direct relation between the baseline analgesia and the breakthrough dose. Titration can be difficult and lengthy as the recommended starting dose is 200 μg with titration upwards (Portenoy et al. 1999). It is recommended that the lozenge be removed from the mouth if the pain subsides before it has completely dissolved. The lozenge should not be reused but should be dissolved under running hot water.
Fentanyl buccal tablet (Effentora)
This is a newly licensed medication for the treatment of breakthrough pain in adults with cancer who are already receiving a maintenance opioid for chronic cancer. Patients receiving maintenance opioid therapy are those who are taking at least 60 mg of oral morphine daily, at least 25 μg of transdermal fentanyl per hour, at least 30 mg of oxycodone daily, at least 8 mg of oral hydromorphone daily or an equi-analgesic dose of another opioid for a week or longer. This buccal tablet is available in 100, 200, 400, 600 and 800 μg. It is placed on the oral mucosa above the third upper molar which leads to the tablet being dissolved by the saliva. It usually takes 15–25 minutes for the tablet to dissolve. It is recommended that if the tablet has not completely dissolved within 30 minutes then the remainder of the tablet should be swallowed with water as it is thought that the tablet will then only be likely to consist of inactive properties rather than active fentanyl (Darwish et al. 2007).
Abstral is an oral transmucosal delivery formulation of fentanyl citrate, indicated for the management of breakthrough pain in patients using opioid therapy for chronic cancer pain (Rauch et al. 2009). The tablet is administered sublingually and it rapidly disintegrates, ensuring the fentanyl dissolves quickly. Abstral is available in six dosing strengths: 100, 200, 300, 400, 600 and 800 μg fentanyl citrate.
Adjuvant drugs (co-analgesics)
Adjuvant drugs are a miscellaneous group whose primary indication is for conditions other than pain which may, however, relieve pain in specific circumstances (Twycross and Wilcock 2001). Examples of this category include NSAIDs, steroids, antibiotics, antidepressants, antiepileptics, N-methyl-D-aspartate (NMDA) receptor channel blockers, antispasmodics and muscle relaxants (Twycross and Wilcock 2001).
The WHO analgesic ladder recommends the use of these drugs in combination with non-opioids, opioids for mild to moderate pain and opioids for moderate to severe pain (see Figure 9.12).
Nitrous oxide (Entonox)
Inhaled nitrous oxide provides analgesia that is short acting and works quickly. It has a special role in managing pain associated with wound dressings and drain removal.
Local anaesthetics
In addition to epidural analgesia, local anaesthetics may be used to block individual or groups of peripheral nerves during surgical procedures and to infiltrate surgical wounds at the end of an operation (Carroll and Bowsher 1993). Occasionally these techniques may be used to extend the duration of postoperative analgesia beyond the finite period that a single injection technique provides (Macintyre et al. 2010). Techniques include regular intermittent bolus doses or continuous infusions of local anaesthetic.
A topical preparation (patch) containing local anaesthetic is also