Medicines Used to Relieve Pain

Opioids

These medicines are used alone or with nonopioids to treat moderate to severe pain. Opioids are similar to natural substances (endorphins) produced by the body to control pain. Some work better than others in relieving severe pain. These medicines were once made from the opium poppy, but today many are synthetic, that is, they are chemicals made by drug companies. See the table below for examples of opioids. 

Opioids Generic Name: Codeine, Hydromorphone, Levorphanol Methadone, Morphine, Oxycodone, Meperidine, Oxymorphone, Fentanyl

Combination Opioid/NSAID preparations: Codeine (with aspirin or acetaminophen), Oxycodone, Hydrocodone

What Is Drug Tolerance?

People who take opioids for pain sometimes find that over time they need to take larger doses. This may be due to an increase in the pain or the development of drug tolerance. Drug tolerance occurs when your body gets used to the medicine you are taking, and your medicine does not relieve the pain as well as it once did. Many people do not develop a tolerance to opioids. If tolerance does develop, usually small increases in the dose or a change in the kind of medicine will help relieve the pain.
Increasing the doses of opioids to relieve increasing pain or to overcome drug tolerance does NOT lead to addiction.

How to Get Proper Pain Relief With Opioids

When a medicine does not give you enough pain relief, your doctor may increase the dose or how often you take it. With careful medical observation, the doses of strong opioids can be raised safely to ease severe pain. Do not increase the dose of your pain medicine on your own. If these measures do not work, the doctor may prescribe a different or additional drug. Some opioids are stronger than others, and you may need a stronger one to control your pain.

If your pain relief is not lasting long enough, ask your doctor about extended-release medicines, which can control your pain for a longer period of time. Morphine and oxycodone are made in extended-release forms. Also, a skin patch that releases the opioid fentanyl can be used.

If your pain is controlled most of the time, but occasionally breaks through, your physician may prescribe a rapid-acting medicine, such as immediate-release morphine, to give you more pain relief when it is needed.

Precautions When Taking Opioids

Doctors carefully adjust the doses of pain medicines so there is little possibility of taking too much medicine. Therefore, it is important that two different doctors do not prescribe opioids for you unless they talk to one another about it.

If you drink alcohol or take tranquilizers, sleeping aids, antidepressants, antihistamines, or any other medicines that make you sleepy, tell your doctor how much and how often you take these medicines. Combinations of opioids, alcohol, and tranquilizers can be dangerous. Even small doses may cause problems.

Using such combinations can lead to overdose symptoms such as weakness, difficulty in breathing, confusion, anxiety, or more severe drowsiness or dizziness.

Side Effects of Opioids

Not everyone has side effects from opioids. Those that do occur are usually drowsiness, constipation, nausea, and vomiting. Some people might also experience dizziness, mental effects (nightmares, confusion, hallucinations), a moderate decrease in rate and depth of breathing, difficulty in urinating, or itching.

Drowsiness

At first, opioids cause drowsiness in some people, but this usually goes away after a few days. If your pain has kept you from sleeping, you may sleep more for a few days after beginning to take opioids while you "catch up" on your sleep. Drowsiness will also lessen as your body gets used to the medicine. Call your doctor or nurse if you feel too drowsy for your normal activities after you have been taking the medicine for a week.

Sometimes it may be unsafe for you to drive a car, or even to walk up and down stairs alone. Avoid operating heavy equipment or performing activities that require alertness.

Here are some ways to handle drowsiness:

* Wait a few days and see if it disappears.
* Check to see if other medicines you are taking can also cause drowsiness.
* Ask the doctor if you can take a smaller dose more frequently or an extended-release opioid.
* If the opioid is not relieving the pain, the pain itself may be wearing you out. In this case, better pain relief may result in less drowsiness. Ask your doctor what you can do to get better pain relief.
* Sometimes a small decrease in the dose of an opioid will still give you pain relief but no drowsiness. If drowsiness is severe, you may be taking more opioid than you need. Ask your doctor about lowering the amount you are now taking.
* Ask your doctor about changing to a different medicine.
* Ask your doctor if you can take a mild stimulant such as caffeine.
* If drowsiness is severe or if it occurs suddenly after you have been taking opioids for a while, call your doctor or nurse right away.

Constipation

Opioids cause constipation to some degree in most people. Opioids cause the stool to move more slowly along the intestinal tract, thus allowing more time for water to be absorbed by the body. The stool then becomes hard. Constipation can often be prevented and/or controlled.

After checking with your doctor or nurse, you can try the following to prevent constipation:

* Ask your doctor to recommend a stool softener, and how often and how much you should take.
* Drink plenty of liquids. Eight to ten 8-ounce glasses of fluid each day will help keep your stools soft. This is the most important step!
* Eat foods high in fiber or roughage such as uncooked fruits (with the skin on), vegetables, and whole grain breads and cereals.
* Add 1 or 2 tablespoons of unprocessed bran to your food. This adds bulk and stimulates bowel movements.
* Keep a shaker of bran handy at mealtimes to make it easy to sprinkle on foods.
* Exercise as much as you are able.
* Eat foods that have helped relieve constipation in the past.
* If you are confined to bed, try to use the toilet or bedside commode when you have a bowel movement, even if that is the only time you get out of bed.

If you are still constipated after trying all the above measures, ask your doctor to prescribe a stool softener or laxative. Be sure to check with your doctor or nurse before taking any laxative or stool softener on your own. If you have not had a bowel movement for 2 days or more, call your doctor.

Nausea and Vomiting

Nausea and vomiting caused by opioids will usually disappear after a few days of taking the medicine. The following ideas may be helpful:

* If nausea occurs mainly when you are walking around (as opposed to being in bed), remain in bed for an hour or so after you take your medicine. This type of nausea is like motion sickness. Sometimes over-the-counter medicines such as meclizine or dimenhydrinate help this type of nausea. Check with your doctor or nurse before taking these medicines.
* If pain itself is the cause of the nausea, using opioids to relieve the pain usually makes the nausea go away.
* Medicines that relieve nausea can sometimes be prescribed.
* Ask your doctor or nurse if the cancer, some other medical condition, or other medicine you are taking such as steroids, anticancer drugs, or aspirin might be causing your nausea. Constipation may also contribute to nausea.

Some people think they are allergic to opioids if they cause nausea. Nausea and vomiting alone usually are not allergic responses. But a rash or itching along with nausea and vomiting may be an allergic reaction. If this occurs, stop taking the medicine and tell your doctor at once.

When You No Longer Need Opioids

You should not stop taking opioids suddenly. People who stop taking opioids are usually taken off the medicine gradually so that any withdrawal symptoms will be mild or scarcely noticeable. If you stop taking opioids suddenly and develop a flu-like illness, excessive perspiration, diarrhea, or any other unusual reaction, tell your doctor or nurse. These symptoms can be treated and tend to disappear in a few days to a few weeks.

Other Types of Pain Medicine

Several different classes of medicines can be used along with (or instead of) opioids to relieve cancer pain. They may relieve pain or may increase the effect of opioids. Others lessen the side effects of opioids. The following chart shows the classes of nonopioid medicines that might be prescribed by your doctor to help you get the best pain relief with as few side effects as possible.

Antidepressants: include Amitriptyline, Nortriptyline, and Desipramine.  Antidepressants are used to treat tingling or burning pain from damaged nerves.  Nerve injury can result from surgery, radiation therapy, or chemotherapy.  Side effects include dry mouth, sleepiness, constipation, drop in blood pressure with dizziness or fainting when standing. Blurred vision. Urinary retention. Patients with heart disease may have an irregular heartbeat.

Antihistamines:  Hydroxyzine Diphenhydramine helps control nausea and help people sleep. Helps control itching. Side effects include drowsiness.

Anti-anxiety drugs: Such as Diazepam and Lorazepam.  Used to treat muscle spasms that often go along with severe pain. Also lessen anxiety. Drowsiness. May cause urinary incontinence. 

Amphetamines: Caffeine, Dextroamphetamine, and Methylphenidate. Increase the pain relieving action of opioids and reduce the drowsiness they cause. Side effects include irritability, rapid heartbeat, and decreased appetite. 

Anticonvulsants:  Carbamazepine, Clonazepam, Gabapentin, Phenytoin. Help to control tingling or burning from nerve injury caused by the cancer or cancer therapy.  May cause liver problems and lowered number of red and white cells in the blood. Gabapentin may cause sedation and dizziness. 

Steroids: Dexamethasone and  Prednisone.  Help relieve bone pain, pain caused by spinal cord and brain tumors, and pain caused by inflammation. Increase appetite. Side effects include fluid buildup in the body. Increased blood sugar. Stomach irritation. Rarely, confusion, altered behavior, and sleeplessness.

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