Hi ! I'm Dr Kishori. I'm an ENT specialist practicing at Prerana Polyclinic, JP Nagar 1st phase, Bangalore.
This post is for doctors. It is about pain management in patients suffering from ROCM.
Pain is a predominant symptom of Rhino-orbito-cerebral mucor mycosis (black fungus). Headache is usually the first symptom of the disease. As the disease progresses, pain becomes severe, relentless and intractable, causing considerable suffering to patients and caretakers. Pain is promptly relieved by Surgery and Amphotericin B. But sadly there are many patients who have advanced disease which is incurable. Patients with extensive intracranial spread, cavernous sinus involvement, large cerebral infarctions, patients with poor general conditions due to comorbidities are not amenable to curative treatment. Most terminally ill mucor patients continue to suffer from excruciating headaches day and night which make their final days utterly miserable. We've all had mucor patients begging us to relieve them of their pain. Palliative care of terminal mucor patients has to be taken seriously. As doctors it is our duty to make them comfortable and pain free in their final moments. NSAIDs do not offer much relief in mucor associated pain.
Transdermal opioid patches (TDP) are extensively used by surgeons to relieve post operative pain and by oncologists to relieve cancer associated pain. The most commonly used opioids are Fentanyl, Buprenorphine and Oxycodone. Transdermal patches must be considered for relieving severe pain associated with ROCM patients who are terminally ill and also in those who are awaiting their for treatment. Patches are very convenient and easy to use. They can be applied and changed at home. The following do's and don'ts have to be followed which should be clearly conveyed to the caregiver. Patch should be applied over a hairless part of the body after washing and drying the area thoroughly. Exposure to excessive heat in the form of heated water beds, exposure to sun and long hot baths must be avoided since heat tends to hasten the dissipation of the drug through the skin. Each patch lasts for 3 - 6 days and should be replaced by a new one. The used patch must be disposed of properly and should be kept out of reach of children. Sudden discontinuation of the patch should be avoided since it can cause withdrawal symptoms. One of the drawbacks of Opioid TDPs is that it can take 24 - 48 hours to bring about pain relief. Opioid patches can produce side effects like drowsiness, dizziness, fatigue, constipation, nausea, vomiting, excessive sweating and pruritus.
Opioid TDPs are far safer than systemic opioids but comparable in efficacy. However they have a few contraindications which must be kept in mind. They are better avoided in alcoholic patients and patients on sedatives, anticonvulsants and antidepressants since it increases the chance of respiratory depression. They are also better avoided in patients with asthma and COPD. Some antibiotics like erythromycin and roxithromycin cannot be used concurrently. They can also be habit forming. In case of doubt a physician should be consulted.
Opioid TDPs are available in various strengths and are very affordable. Fentanyl TDPs are available in strengths of 12mg, 25mg, 50mg, 75mg and 100mg costing between Rs 600 - Rs 1,500 for a pack of two. Buprenorphine TDPs are available in strengths of 5mg, 10mg and 20mg costing between Rs 2000 - Rs 3500 for a pack of two. Many brands are available in the market.
Please consider using Opioid TDPs in ROC mucor mycosis patients who are terminally ill or awaiting treatment. They are easy to use, affordable and widely available even in smaller cities. They do not require hospitalization. They offer adequate and sustained relief. They are generally safe.
I'm Dr Kishori signing off. For any inputs please mail me at firstname.lastname@example.org
Thank you and Bubye !
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