While my previous entry identified the types of pain often found with cancer or from its treatment, it's also important to review the use of common, overt-the-counter medications that are generally used to treat pain, especially when working with moderate to severe levels of pain.

Treating Moderate Pain

For moderate pain (rated 4-6 on the 10 point scale), it is common to need a medicine stronger than the familiar pain remedies such as acetaminophen (Tylenol ® and others), aspirin or non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen (Motrin® and others) or naproxen (Alleve ® and others). Keep in mind, the next strongest group of medications is to be used, though they bear the burden of much misinformation and misunderstanding. Opioid analgesics, sometimes called narcotic pain medications, are added to the acetaminophen or NSAIDs to get relief beyond the limitations for each. That frightens most people. "That means the cancer is bad" or "That's for addicts, not for me" and the biggest challenge is taking the right amount that relieves the pain without a sense of euphoria or impairment keeping track of things or even staying awake.  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, despite a good understanding of their correct use. For those patients who have never over-used painkillers, alcohol, tranquilizers or street drugs before their cancer developed 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 or synthetic, and is often already mixed with acetaminophen. But to control each, best to use separate pills, one with the acetaminophen (or NSAID) and the other of codeine. Hydrocodone, oxycodone or codeine sulfate are the most common forms available in the United States today. In the basic pill formula or liquid, they generally relieve pain for 3-4 hours, and when taken with acetaminophen or an NSAID, can be effective for longer, even 6-8 hours. Any of the forms cause the bowels to slow down, and the resulting constipation can be prevented by using stool softeners like docusate (Colace ® and others) with every dose or every other dose along with extra fluids and psyllium products (Metamucil and others), taken in-between doses of pain medications.  Driving or using other machinery should be avoided until a stable does is reached, since the tiredness, sedation or forgetfulness generally wears off then. Because they are generally helpful for 3-4 hours, using a smaller regular 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, for those treated for head & neck, esophageal or lung cancers. Those whose chemotherapy gives diarrhea also benefit from their constipating qualities.

Treating Severe 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 them are astounding. "That's for dying people" or "that kills people" are greatly inaccurate. The body works harder to digest codeine into morphine so it can work, so taking morphine gets more relief more easily. It also lasts only 3-4 hours, and has the same side effect profile as codeine. Sometimes, since heroin was referred to as "morphine" back in the 1940s and 1950s, the biases are even further exaggerated thinking about 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, so 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 for 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, minimizing the total amounts used. It is the long-acting codeine tablets (OxyContin ® and others) that have become attractive street drugs, crushed and snorted, that have made it one of the most sought after drugs for abuse, yet it is the long-acting coating that makes it ideal for use every 8 or 12 hours for cancer pain. A common and effective long-acting medication is methadone, especially for those with limited or no prescription drug benefits. Misperceptions abound. 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 Pain 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. Prevention and control of constipation may require laxatives in addition to stool softeners and psyllium fiber supplements. 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. As can difficulty urinating related to the use of pain 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 the dependence) is not only a bad idea but could wind up in an avoidable hospital admission or even death. Have your treatment team where you are getting treated for cancer 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.

A future entry will describe how varying types of pain need different approaches: other types of medications and non-medication techniques such as massage, acupuncture or yoga. The importance of good communication with experienced providers will also be addressed.