MEDICATIONS: PAIN CONTROL GUIDE FOR PEOPLE WITH CANCER: MEDICINES TO TREAT CANCER PAIN

There is more than one way to treat pain.

Your doctor prescribes medicine based on the kind of pain you have and how severe it is. In studies, these medicines have been shown to help control cancer pain. Doctors use three main groups of drugs for pain: nonopioids, opioids and other types. You also may hear the term analgesics used for these pain relievers. Some are stronger than others. It helps to know the different kinds of medicines, why and how they're used, how you take them and what side effects you might expect.

1. Nonopioids — for mild to moderate pain

Nonopioids are drugs used to treat mild to moderate pain, fever and swelling. On a scale of 0 to 10, a nonopioid may be used if you rate your pain from 1 to 4. These medicines are stronger than most people realize. In many cases, they are all you'll need to relieve your pain. You just need to be sure to take them regularly.

You can buy most nonopioids without a prescription. But you still need to talk with your doctor before taking them. Some of them may have things added to them that you need to know about. And they do have side effects. Common ones, such as nausea, itching or drowsiness, usually go away after a few days. Do not take more than the label says unless your doctor tells you to do so.

Nonopioids include:

· Acetaminophen, which you may know as Tylenol®
Acetaminophen reduces pain. It is not helpful with inflammation. Most of the time, people don't have side effects from a normal dose of acetaminophen. But taking large doses of this medicine every day for a long time can damage your liver. Drinking alcohol with the typical dose also can damage the liver.

Make sure you tell the doctor that you're taking acetaminophen. Sometimes it is used in other pain medicines, so you may not realize that you're taking more than you should. Also, your doctor may not want you to take acetaminophen too often if you're getting chemotherapy. The medicine can cover up a fever, hiding the fact that you might have an infection.

· Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (which you may know as Advil® or Motrin®) and aspirin
NSAIDs help control pain and inflammation. With NSAIDs, the most common side effect is stomach upset or indigestion, especially in older people. Eating food or drinking milk when you take these drugs may stop this from happening.

NSAIDs also may keep blood from clotting the way it should. This means that it's harder to stop bleeding after you've hurt yourself. NSAIDs also can sometimes cause bleeding in the stomach.

Tell your doctor if:

· Your stools become darker than normal

· You notice bleeding from your rectum

· You have an upset stomach

· You have heartburn symptoms

· You cough up blood

Acetaminophen and NSAIDs at a Glance
Type	Other Names	Action	Side Effects
Acetaminophen	Tylenol®	Reduces pain and fever	Large doses can damage the liver. May cause liver damage if you drink three or more alcoholic drinks a day. Lowers fever. Talk to your doctor if your body temperature is above normal (98.6 degrees) and you are taking this medicine.
NSAIDs (aspirin, ibuprofen, naproxen)	Bayer® (aspirin) Ecotrin® (aspirin) Advil® (ibuprofen) Motrin® (ibuprofen) Nuprin® (ibuprofen) Aleve® (naproxen)	Reduces pain, inflammation (swelling) and fever	Can upset the stomach. Can cause bleeding of the stomach lining, especially if you drink alcohol (wine, beer, etc.). Can cause kidney problems, especially in the elderly or those with existing kidney problems. Can cause heart problems, especially in those who already have heart disease. However, aspirin does not cause heart problems. Avoid these medicines if you are on anticancer drugs that may cause bleeding. Lowers fever. Talk to your doctor if your body temperature is above normal (98.6 degrees) and you are taking this medicine.

What to Avoid When Taking NSAIDs

Some people have conditions that NSAIDs can make worse. In general, you should avoid these drugs if you:

· Are allergic to aspirin

· Are getting chemotherapy

· Are on steroid medicines

· Have stomach ulcers or a history of ulcers, gout or bleeding disorders

· Are taking prescription medicines for arthritis

· Have kidney problems

· Have heart problems

· Are planning surgery within a week

· Are taking blood-thinning medicine (such as Coumadin®)

2. Opioids — for moderate to severe pain

If you're having moderate to severe pain, your doctor may recommend that you take stronger drugs called opioids. Opioids also are known as narcotics. You must have a doctor's prescription to take them. They often are taken with aspirin, ibuprofen and acetaminophen.

Common opioids include:

· Codeine

· Fentanyl

· Hydromorphone

· Levorphanol

· Meperidine

· Methadone

· Morphine

· Oxycodone

· Oxymorphone

Getting Relief With Opioids
Over time, people who take opioids for pain sometimes find that they need to take larger doses to get relief. This is caused by more pain, the cancer getting worse or medicine tolerance. When a medicine doesn't give you enough pain relief, your doctor may increase the dose and how often you take it. He or she also can prescribe a stronger drug. Both methods are safe and effective under your doctor's care. Do not increase the dose of medicine on your own.

Managing and Preventing Side Effects
Some pain medicines may cause:

· Constipation (trouble passing stools)

· Drowsiness (feeling sleepy)

· Nausea (upset stomach)

· Vomiting (throwing up)

Usually these side effects last only a few days. But if they last longer, your doctors can change the medicine or dose you're taking. Or they also may add another medicine to your pain control plan to control the side effects. Keep in mind that constipation will only go away if it's treated. Your health care team can talk with you about other ways to relieve side effects. Don't let side effects stop you from getting your pain under control.

Other less common side effects include:

· Dizziness

· Confusion

· Breathing problems

· Itching

· Trouble urinating

Constipation
Almost everyone taking opioids has some constipation. This happens because opioids cause the stool to move more slowly through your system, so your body takes more time to absorb water from the stool. The stool then becomes hard.

You can control or prevent constipation by taking these steps:

· Ask your doctor about giving you laxatives and stool softeners when you first start taking opioids. Taking these right when you start taking pain medicine may prevent the problem.

· Drink plenty of liquids. Drinking eight to 10 glasses of liquid each day will help keep stools soft.

· Eat foods high in fiber, including raw fruits with the skin left on, vegetables, and whole grain breads and cereals.

· Add 1 tablespoon to 2 tablespoons of bran to your food or sprinkle it on your food. Remember to drink a glass of water when you eat bran, or it will make the problem worse.

· Exercise as much as you are able. Any movement, such as light walking, will help.

· Call your doctor if you have not had a bowel movement in two days or more.

Drowsiness
If your pain has kept you from sleeping, you may sleep more at first when you begin taking opioids. The drowsiness usually goes away after a few days.

If you are tired or drowsy:

· Don't walk up and down stairs alone.

· Don't do anything where you need to be alert — driving, using machines or equipment, or anything else that requires focus.

· Call your doctor if the drowsiness is severe or doesn't go away after a week.

· You may have to take a smaller dose more often or change medicines.

· It may be that the medicine isn't relieving your pain, and the pain is keeping you awake at night.

· Your other medicines may be causing the drowsiness.

· Your doctor may decide to add a new drug that will help you stay awake.

Nausea and Vomiting
Nausea and vomiting usually go away after a few days of taking opioids.

These tips may help:

· Stay in bed for an hour or so after taking your medicine if you feel sick when walking around. This kind of nausea is like feeling seasick. Some over-the-counter drugs may help, too. But be sure to check with your doctor before taking any other medicines.

· You may want to ask your doctor to prescribe anti-nausea drugs.

· Ask your doctor if something else could be making you feel sick. It might be related to your cancer or another medicine you're taking. Constipation can also add to nausea.

Starting a New Pain Medicine

Some pain medicines can make you feel sleepy when you first take them. This usually goes away within a few days. Also, some people get dizzy or feel confused. Tell your doctor if any of these symptoms persist. Changing your dose or the type of medicine can usually solve the problem.

What to Watch Out for When Taking Pain Medicine

All drugs must be taken carefully. Here are a few things to remember when you are taking opioids:

· Take your medicines as directed. Also, don't split, chew or crush them, unless suggested by your doctor.

· Doctors will adjust the pain medicine dose so that you get the right amount for your body. That's why it's important that only one doctor prescribes your opioids. Make sure that you bring your list of medicines to each visit. That way, your health care team is aware of your pain control plan.

· Combining pain medicine with alcohol or tranquilizers can be dangerous. You could have trouble breathing or feel confused, anxious or dizzy.

Tell your doctor how much and how often you:

· Drink alcohol

· Take tranquilizers, sleeping pills or antidepressants

· Take any other medicines that make you sleepy

How to Stop Taking Opioids

You may be able to take less medicine when the pain gets better. You may even be able to stop taking opioids. But it's important to stop taking opioids slowly, with your doctor's advice. When pain medicines are taken for long periods of time, your body gets used to them. If the medicines are stopped or suddenly reduced, a condition called withdrawal may occur. This is why the doses should be lowered slowly. This has no relation to being addicted. Stopping your pain medicines slowly makes withdrawal symptoms mild. But if you stop taking opioids suddenly, you may start feeling like you have the flu. You may sweat and have diarrhea or other symptoms. If this happens, tell your doctor or nurse. He or she can treat these symptoms. Any symptoms from withdrawal may take a few days to a few weeks to go away.

3. Other types of pain medicine

Doctors also prescribe other types of medicine to relieve cancer pain. They can be used along with nonopioids and opioids. Some include:

· Antidepressants. Some drugs can be used for more than one purpose. For example, antidepressants are used to treat depression, but they also may help relieve tingling and burning pain. Nerve damage from radiation, surgery or chemotherapy can cause this type of pain.

· Antiseizure medicines (anticonvulsants). Like antidepressants, anticonvulsants or antiseizure drugs also can be used to help control tingling or burning from nerve injury.

· Steroids. Steroids are mainly used to treat pain caused by swelling.

Be sure to ask your health care team about the common side effects of these medicines.

How Medicine Is Given

To relieve cancer pain, doctors often prescribe pills or liquids. But there also are other ways to take medicines, such as:

· Mouth. Some pain medicine can be put inside the cheek or under the tongue.

· Injections (shots). There are two different kinds of shots:

o Under the skin. Medicine is placed just under the skin using a small needle. These are called subcutaneous injections.

o In the vein. Medicine goes directly into the vein through a needle. These are called intravenous (IV) injections. Patient-controlled analgesia (PCA) pumps are often used with these kinds of injections. PCA pumps let you push a button to give yourself a dose of pain medicine.

· Skin patches. These bandage-like patches go on the skin. They slowly but steadily, release medicine for two to three days.

· Rectal suppositories. These are capsules or pills that you put inside your rectum. The medicine dissolves and is absorbed by the body.

· Around the spinal cord. Medicine is placed between the wall of the spinal canal and the covering of the spinal cord (called an epidural).

Questions to ask your health care team about your pain medicine:

How much medicine should I take?

How often?

If my pain doesn't go away, can I take more medicine?

How much should I increase the dose?

Should I call you before taking more medicine?

How long does the medicine last?

What if I forget to take my medicine or take it later than I was supposed to?

Should I take my medicine with food?

How much liquid should I drink with the medicine?

How long does it take for the medicine to start working?

Is it safe to drink alcohol (wine, beer, etc.), drive, or run machinery after I've taken the medicine?

What other medicines can I take with the pain medicine?

What are the side effects? How can I prevent them?

What should I call you about right away?

Other Ways to Relieve Pain

Medicine doesn't always relieve pain in some people. In these cases, doctors use other treatments to reduce pain: · Radiation therapy. Different forms of radiation energy are used to shrink the tumor and reduce pain. Often one treatment is enough to help with the pain. But sometimes several treatments are needed. · Neurosurgery. A surgeon cuts the nerves that carry pain messages to your brain. · Nerve blocks. Anesthesiologists inject pain medicine into or around the nerve or into the spine to relieve pain. · Surgery. A surgeon removes all or part of a tumor to relieve pain. This is especially helpful when a tumor presses on nerves or other parts of the body. · Chemotherapy. Anticancer drugs are used to reduce the size of a tumor, which may help with the pain. · Transcutaneous Electric Nerve Stimulation (TENS). TENS uses a gentle electric current to relieve pain. The current comes from a small power pack that you can hold or attach to yourself.

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