In last week’s column I identified the types of pain often found with cancer, as well as the treatment of minor pain with over-the-counter pain medications.
For moderate pain (rated 4-6 on the 10 point scale), it is common to need a medicine stronger than the familiar remedies such as acetaminophen, aspirin, or non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen. The next strongest group of medicine bears the burden of much misinformation and misunderstanding.
Opioid analgesics, which are sometimes called narcotic pain medications, are often added to acetaminophen or NSAIDs to boost their pain relieving ability. That frightens many cancer patients.
“That means the cancer is bad” or “that’s for addicts, not for me,” are common reactions.
The biggest challenge is taking the right amount of these medicines to relieve pain without a sense of euphoria, mental impairment or difficulty staying awake.
Treating Moderate Cancer Pain
Moderate pain generally calls for codeine-containing medications, and due to much publicity about their abuse in the non-cancer world, reluctance to use them is extraordinarily high. For those patients who have never overused painkillers, alcohol, tranquilizers or street drugs before, and do not have close blood relatives with substance abuse problems, the chance of addiction is extremely low. Yet the fear is high.
Codeine comes in a variety of forms, natural, semi-synthetic (hydrocodone, oxycodone and others) or synthetic (methadone, fentanyl and others); and are often mixed with acetaminophen. To control each, I believe it is best to use separate pills, one with acetaminophen (or an NSAID) and the other of codeine.
Hydrocodone, oxycodone or codeine sulfate are the most common forms available in the United States. In the basic pill form or liquid, they generally relieve pain for 3-4 hours. When taken with acetaminophen or an NSAID, they can be effective for longer, even 6-8 hours.
Opioids often cause the bowels to slow down, and the resulting constipation can be prevented by using laxatives or stool softeners like docusate (Colace and others), or with extra fluids or psyllium products (Metamucil and others), taken in-between doses of pain medications.
Driving or operating machinery should be avoided until a stable dose is reached, since the tiredness, sedation or forgetfulness generally wears off by then. Because they are often helpful for 3-4 hours, using a smaller dose every three hours is much more effective than waiting a longer period of time that exceeds the time they are active in controlling pain.
The codeines also control cough and even help dry excess mucus, a common side effect for those treated for head and neck, esophageal or lung cancers. Those whose chemotherapy causes diarrhea also benefit from their constipating qualities.
Treating Severe Cancer Pain
Pain rated 7-10 is most likely treated with a different form of opioid that is accompanied with great misunderstanding. Medications in the morphine family are surprisingly among the least expensive and easiest for the body to digest, yet the misplaced biases against morphine is astounding.
“That’s for dying people” or “that kills people” are greatly inaccurate.
The body works harder to digest codeine into morphine, so taking morphine directly provides relief sooner. It also lasts only 3-4 hours, and has the same side effect profile as codeine.
Since heroin was referred to as “morphine” back in the 1940s and 1950s, the biases against it are even further exaggerated because of those who used it for mood-altering or recreational purposes, not cancer pain.
Both codeine and morphine products are available in various types of long-acting preparations. Once a proper dose is established with the short-acting versions, they can be switched to the longer acting types that can be given one, two or three times a day (rather than every 3-4 hours) at lower doses, since the long-acting preparations stay active longer in the body.
An ultra-short acting form of morphine embedded in a skin patch can last for 72 hours, keeping a steady low-dose available and minimizing the total amounts used.
It is the long-acting codeine tablets (OxyContin and others) that have become attractive street drugs. When crushed and snorted, they are one of the most sought after drugs for abuse, yet it is their long-acting coating that makes the pills ideal for use every 8 or 12 hours for cancer pain.
Another common and effective long-acting medication is methadone, especially for those with limited or no prescription drug benefits. Misperceptions abound about methadone. When used for cancer pain, rather than maintenance for substance abuse, methadone is available in pharmacies by pill or liquid form.
Knowing the proper form, dose and schedule of medications to use involves both experience and skill. Using the smallest fixed amount of a long-acting preparation allows you to add additional doses of a short acting version from the same family of medications to judge if dose increases are only transient or necessary for the long-acting variety.
This approach allows you to test the dose estimates of medications in your own real-life setting. It requires a good working relationship with your treatment team and specialists.
A time-tested way to minimize getting used to any one type of medication is to routinely “rotate” opioid substances between families, slowing the time until increased doses are needed to achieve the same level of pain control.
Side Effects and Tapering Off Opioid Medications
Keeping a pain diary will help you and the prescriber know the minimal effective dose, and keep the side effects to a minimum as well. If analgesics are helpful, but make you too groggy, judicious use of stimulant medicines can help counteract the sedation during the daytime. Caution should be used to mix drugs carefully and slowly. Nausea can likewise be treated with anti-nausea (antiemetic) medications.
With effective chemotherapy and radiation therapy or incorporating non-medication forms of pain relief, the cause for the pain or need for full dose analgesics may cease, and it is vital to keep in mind that stopping pain medications abruptly (out of fear or frustration with dependence) is not only a bad idea, but could lead to hospital admission or even death.
Have your cancer treatment team work out a logical schedule based upon what doses you used over what period of time. Coming off these medications generally takes a few weeks or even longer if you are in the “low risk” group described.
In next week’s column I will describe how varying types of pain need different approaches, other types of pain medications, and non-medication techniques such as massage, acupuncture and yoga.
Stewart Fleishman, MD, is the former Director of Cancer Supportive Services at the Continuum Cancer Centers of New York and the Associate Chief Medical Officer of Continuum Hospice Care-Jacob Perlow Hospice.
His practice was focused on pain management, symptom control and palliative care. Dr. Fleishman’s was actively involved in research focused on quality of life and symptom control in people with cancer, and serves on national committees dedicated to this work. He is Board Certified in both Hospice and Palliative Medicine and Psychiatry/Neurology.
Dr. Fleishman’s book Learn to Live Through Cancer: What You Need to Know and Do presents a step-by-step guide to improve the length and quality of life for cancer survivors, helping them to manage the variety of physical, emotional, and spiritual issues they face proactively.
Dr. Fleishman also writes for Demos Health Publishing’s blog.