Pain
Pharmacological Treatment

Non-opioids
Acetaminophen, aspirin or other nonsteroidals (ibuprofen) are commonly used to treat mild pain. These drugs are available “over the counter” without a physician's prescription. It is important for you to check with your healthcare team before taking these medicines. The aspirin and nonsteroidals can cause stomach irritation and problems with blood clotting or interact with other medicine you may be taking.

Opioids
Opioids are commonly called narcotics that are used to control severe pain.

1. Morphine is available as a long acting morphine. Small, regular doses of morphine are released in your body after the drug is swallowed to provide control of pain. Long acting morphine is available in several brands, MS Contin^®, Kadian^®, Avinza^® (formerly called Morphelan^TM). It is important for these medications to be taken on a regular schedule. Generally the schedule for the long acting morphine is every twelve hours based on your need. There is also a daily morphine. You should never stop these medications suddenly. Always discuss any changes with your healthcare team. These medications should never be chewed or crushed; they should always be swallowed whole. ² This medicine requires a prescription.



2. Immediate release morphine is available as MSIR, Roxanol^®, MS/S suppositories and others. They are available as tablets, liquids, suppositories or injections. If you have to use immediate release morphine frequently, you should check with your healthcare team. The long acting morphine may need to be increased or there could be another problem causing the pain. This medicine requires a prescription.



3. Long acting oxycodone is also known as OxyContin^®. This drug is available in tablet form and lasts for twelve hours. This drug also requires a physician's prescription. This drug should not be broken or split, but swallowed whole.



4. Short acting oxycodone has a trade name of Roxicodone^®. Oxycodone is also available in the generic form. This medicine lasts for three to four hours. Forms available are tablets, liquid, and suppositories. A physician's prescription is required to receive this drug.



5. Hydromorphone is a short acting medication, also known as Dilaudid^®, Dilaudid HP^®, and HydroStat^®. Hydromorphone can be found as tablets, suppositories and injection. This medication requires a physician's prescription.



6. Methadone can be found as dolophine and Methadose^®. The forms available are tablets, liquid and injection. This medicine often needs adjustment to maintain pain control. This medication requires a physician's prescription.



7. Oxycodone can be found in the short acting form combined with other medicines. Oxycodone with aspirin is Percodan^® or Roxiprin^®; Oxycodone with acetaminophen is Percocet^®or Tylox^®. These medications are limited in severe pain due to the ceiling effect for aspirin and acetaminophen. Ceiling effect is a dose beyond which further increases in dose do not provide additional analgesia. ⁴ Acetaminophen and nonsteroidals must be used with caution in patients with liver disease and bleeding problems. A physician's prescription is required for this drug.



8. Fentanyl can be found as Duragesic^® patch, Fentanyl Oralet^®, Sublimase^® and Innovar^®. Methods of delivery include transdermal (absorbed through your skin) patch, oral preparation and injection. The transdermal patch may last up to three days. Oralet must be allowed to dissolve slowly in the mouth, so that tablet can be absorbed. This medication requires a physician's prescription.



9. Meperidine also known as Demerol^® is a poor choice for cancer pain. ² The use of this drug for longer than three days can often be associated with agitation, irritability, restlessness, and seizure activity. These symptoms should be reported to the healthcare team immediately. This drug is only given with a physician's prescription.

Adjuvants
An adjuvant is a medicine that has a primary purpose other than pain relief. This group of medicines can be used alone or be given with pain medicines.

1. Antidepressants are often used for pain described as burning or tingling. Among these medications are amitriptyline, nortriptyline and desipramine. The use of these medications does not mean you are depressed or mentally ill. These drugs can only be given with a physician's prescription. This group of drugs can improve your pain relief plan.



2. Antiseizure medications such as gabapentin, carbamazepine and phenytoin can be used to treat burning and tingling pain. These drugs require a physician's prescription.



3. Steroids may be used to help control pain associated with swelling and inflammation. These medications include Prednisone^® and dexamethasone. These drugs are given with a physician's prescription. This group of drugs has the added benefit of increasing appetite and producing a feeling of general well being. These effects are temporary, lasting only while the drug is being taken.

Medicine Administration

Medicine may be given in several different ways, sometimes referred to as routes.

Oral route: given by mouth in pill or capsule.

Skin patch: a small patch placed on the skin. The opioid medicine, fentanyl, is used in this way because it is least likely to cause nausea and vomiting. The placement of choice for this patch is usually the chest because it is better absorbed there. The Lidoderm^® patch is a form of lidocaine and should be placed directly on the site of pain.

Rectal suppositories: medicine placed in the rectum, where it is absorbed. Subcutaneous injection: given with a small needle under the skin.

Intravenous injection: given with a needle into the vein, usually in the intravenous line.

Intrathecal and epidural injections: given directly into the fluid around the spinal cord (intrathecal) or placed in the space around the spinal cord (epidural). ⁷

Intramuscularly (IM): sometimes called a "shot" is given by a needle into the muscle. This is not an appropriate route of treatment for cancer pain.

Pump: Patient controlled analgesia-this route allows you to control the amount of pain medicine you receive. A computerized pump is used and set to allow you to push a button to give yourself a dose of pain medicine. The pump may be programmed to give you a continuous dose of pain medicine and allow you to give yourself a dose, as you need it. The pump may only give you medicine when you push the button. The route this may be used is through the vein, just under the skin or via the spinal area. ⁷

Side Effects Associated With Opioids

All patients will not experience side effects from opioids. It is important to understand the differences between side effects and allergic reactions. An allergic reaction is usually defined as a life-threatening event. A side effect is referred to as a secondary reaction. Breathing may become slower when a patient first begins taking an opioid, but this effect usually subsides as the patient develops a tolerance for this side effect. Patients taking opioids may also experience bad dreams, sweating, itching, and difficulty passing urine or picking at the air with their hands. These side effects can be managed and for that reason a period of days are needed for the body to adjust to the side effects. It is important to talk with your healthcare team and discuss ways of managing side effects.

Constipation
Opioids act on nerves in the bowel, decreasing activity in the bowel. This decreased activity allows time for water to be absorbed from stool as it passes through the bowel. Constipation is the most common side effect and the only one for which patients do not develop a tolerance. ⁴ Prevention is an important part of your plan of care.

Suggestions For Prevention of Constipation

• Use a daily stool softener that includes a stimulant. Ask you healthcare team for suggestions.



• Use a bedside commode when possible if you are confined to bed.



• Try to maintain a schedule that allows for bathroom time.



• If you are having watery stools, you may need to be examined for a fecal impaction. Patients often mistake watery stools for diarrhea and take anti-diarrhea medications. This only makes the problem worse.

Drowsiness

Patients will often experience the disturbing side effect of drowsiness after opioid therapy is begun. Patients often experience sleep deprivation when they are in pain. Once the pain is controlled you may sleep more because your body is tired and you need the rest. The drowsiness will decrease as your body adjusts to the medicine. The healthcare team should be notified if drowsiness continues after a week of taking the opioid medication.

Drowsiness can be a safety risk. You must never drive or operate machinery when you are drowsy. This side effect should only last for 2-3 days.

Managing Drowsiness

• Be aware that other medications you are taking may cause drowsiness. It is important to know the medications you are taking and what they are for.



• After a few days, the drowsiness may disappear.



• Ask you healthcare team if you can take a smaller dose of your pain medicine more frequently. You may tolerate this method with fewer side effects.



• If your pain is unrelieved, the pain may be tiring you and make you feel drowsy. Discuss options for better pain control with your healthcare team. If pain is relieved, but you are still drowsy ask your healthcare team about the possibility of decreasing your pain medication.



• Discuss the use of a mild stimulant such as caffeine with your healthcare team.



• Severe drowsiness or sudden drowsiness while taking opioids should be brought to the attention of your healthcare team immediately.

Managing Nausea and Vomiting

• Take antinausea medications around the clock on the first three days. Ask your healthcare team for instructions. Nausea and vomiting usually subside 2-3 days past beginning opioid therapy.



• Stay in bed for an hour or so after taking pain medicine, if nausea occurs when you are up.



• Eat several small amounts of food throughout the day instead of three large meals a day.



• Eat food such as dry cereal, dry toast, crackers, oatmeal, pretzels, yogurt and sherbet.



• Drink clear liquids such as apple juice, broth, and Jell-O water. Avoid carbonated beverages.



• Avoid fatty foods and sweet or spicy foods.



• Do not lie down for one hour after eating. If you must lie down, elevate your head on more than one pillow.



• Take a relaxing walk in the fresh air.



• Use other methods you may have found useful such as distraction , relaxation or guided imagery.



• A clean mouth will help prevent nausea.



• Pain may be the cause of nausea; if so, the nausea will generally subside when pain is relieved.



• If nausea continues discuss this with your healthcare team. The nausea may be related to another problem.