The type of medicine and the method by which the medicine is given depend on the type and cause of pain. For example, constant, persistent pain is best relieved by methods that deliver a steady dose of pain medicine over a long period of time, such as a patch that is filled with medicine, placed on the skin or slow-release oral tablets. Below is an overview of the types of medicines used to relieve pain.

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FOR MILD TO MODERATE PAIN

NON-OPIOIDS:

Acetaminophen and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as Aspirin and Ibuprofen

You can buy many of these over-the-counter (without a prescription). For others, you need a prescription. Check with your doctor before using these medicines. NSAIDs can slow blood clotting.

FOR MODERATE TO SEVERE PAIN

Opioids(also known as narcotics):

Morphine, Fentanyl, Hydromorphone, Oxycodone, and Codeine

You need a prescription for these medicines. Non-opioids may be used along with opioids for moderate to severe pain.

FOR BREAKTHROUGH PAIN

Rapid-Onset Opioids:

Immediate-release oral Morphine

You need a prescription for these medicines. A short-acting opioid, which relieves breakthrough pain quickly, needs to be used with a long-acting opioid for persistent pain.

FOR TINGLING AND BURNING PAIN

Antidepressants:

Amitriptyline, Nortriptyline, Desipramine

You need a prescription for these medicines. Antidepressants are also prescribed to relieve some types of pain. Taking an antidepressant does not mean that you are depressed or have a mental illness.

Anticonvulsants (antiseizure medicines):

Carbamazepine and Phenytoin

You need a prescription for these medicines. Despite the name, anticonvulsants are used not only for convulsions, but also to control burning and tingling pain.

FOR PAIN CAUSED BY SWELLING

Steroids:

Prednisone, Dexamethasone

A prescription is needed for these medicines. They are used to lessen swelling, which often causes pain.

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HOW IS PAIN MEDICINE GIVEN?

Some people think that if their pain becomes severe, they will need to receive injections or "shots." Actually, there are many ways to get medicine.

ORALLY ; medicine is given in a pill or capsule form.

SKIN PATCH; a bandage-like patch placed on the skin, which slowly but continuously releases the medicine through the skin for 2-3 days. One opioid medicine, fentanyl, is available as a skin patch. This form of medicine is less likely to cause nausea and vomiting.

RECTAL SUPPOSITORIES; medicine that dissolves in the rectum and is absorbed by the body.

INJECTIONS

Subcutaneous (SC) injection � medicine is placed just under the skin using a small needle.

Intravenous (IV) injection ; medicine goes directly into the vein through a needle.

Intrathecal and Epidural injections � medicine is placed directly into the fluid around the spinal cord (intrathecal) or into the space around the spinal cord (epidural).

PUMP

Patient-controlled analgesia (PCA);

With this method, you can help control the amount of pain medicine you take. When you need pain relief, you can receive a preset dose of pain medicine by pressing a button on a computerized pump that is connected to a small tube in your body. The medicine is injected into the vein (intravenously), just under the skin (subcutaneously), or into the spinal area.

If your pain is not well controlled with one of the long-acting oral medicines, if you are having trouble taking pills, or if you are having irritating side effects, ask your doctor about trying one of the methods listed above.

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WHAT ARE THE SIDE EFFECTS OF PAIN MEDICINE?

Many side effects from pain medicine can be prevented. Some mild side effects that do occur, such as nausea, itching, or drowsiness, will usually go away after a few days as your body adjusts to the medicine.

Let your doctor or nurse know if you are having these side effects and ask for help in controlling them.

More serious side effects of pain medicine are rare. As with the more common ones, they usually happen in the first few hours of treatment. They include trouble breathing, dizziness, and rashes. If you have any of these side effects, you should call your doctor right away.

WHICH MEDICINES WILL I BE GIVEN?

In many cases, non-opioids are all you will need to relieve your pain, especially if you "stay on top of the pain" by taking them regularly. These medicines are stronger pain relievers than most people realize.

For example, certain doses of opioids given by mouth are no more effective than two or three regular tablets of aspirin, acetaminophen, or ibuprofen.

If you do not get pain relief from non-opioids, opioids will usually give you the relief you need. Most side effects from opioids can be prevented or controlled.

You should discuss taking opioids along with non-opioids with your doctor, nurse, or pharmacist.

The two types of medicine relieve pain in different ways. Aspirin, Acetaminophen, or Ibuprofen taken four times a day might help avoid or reduce the need for a stronger pain relievers.

Some pain medicines combine an Opioid and a Non-Opioid, like Aspirin or Acetaminophen, in the same pill. Ask your doctor, nurse, or pharmacist how much Aspirin or Acetaminophen, if any, is in your prescription. They can help you figure out how much of these medicines you can take safely.

Other classes of medicines, such as Antidepressants and Anticonvulsants are also used to relieve certain types of cancer pain.

NON-OPIOIDS

Non-Opioids control mild to moderate pain. Some can be bought without a prescription. For detailed information on nonopioids, review the chart below.

Table 1. NON-OPIOIDS � ACETAMINOPHEN AND NSAIDs
TYPE	ACTION	SIDE EFFECTS
Acetaminophen	Reduces pain and fever.	Large doses can injure the liver or kidneys. Use by persons who have 3 or more alcoholic drinks per day may cause liver damage. Acetaminophen reduces fever, so ask your doctor about what to do if your body temperature is greater than normal (98.6�F or 37�C) while you are taking this medicine.
NSAIDs (Nonsteroidal Anti-Inflammatory drugs)
OVER THE COUNTER: Aspirin Ibuprofen Ketoprofen Naproxen sodium PRESCRIPTION: Celecoxib Choline Magnesium Trisalicylate Diclofenac Etodolac Fenoprofen calcium Indomethacin Ketorolac Meclofenamic acid Meclofenamate sodium Nabumetone Naproxen Oxaprozin Piroxicam Rofecoxib Sulindac Tolmetin Sodium	Reduce pain, inflammation, and fever.	NSAID medicines can have the following side effects: Can irritate the stomach. Can cause bleeding of the stomach lining, especially if combined with alcohol. Can cause kidney problems. Avoid these medications if you are on anti-cancer drugs that may cause bleeding. Aspirin and NSAIDs reduce fever, so ask your doctor about what to do if your body temperature is greater than normal (98.6�F or 37�C) while you are taking one of these medicines.

BRAND-NAME DRUGS VERSUS GENERIC DRUGS

Drugs may have as many as three different names: brand, generic, and chemical. Drug companies give their products brand names. The U.S. Food and Drug Administration (FDA) approves the GENERIC, shortened names by which drugs are usually known. Chemical names are long and tend to be hard to pronounce. Here's an example:

Brand name: Tylenol

Generic name: Acetaminophen

Chemical name: N-(4-hydroxyphenyl) Acetamide

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Many pain relievers are available under both generic and brand names. Your doctor, nurse, or pharmacist can tell you the generic name.

Generic products are generally less costly than brand-name drugs. Sometimes medicines can have the same generic name, but are produced by different companies. Because the companies may produce the medicines differently, they may differ in the way they are absorbed by the body.

For this reason, your doctor may prefer that you take a brand-name drug. You might want to ask your doctor, nurse, or pharmacist if you can use a less expensive medication.

Pharmacists are careful to obtain high-quality generic products, so it is sometimes possible to make substitutions.

In addition to the main substance (aspirin, acetaminophen, or ibuprofen), some brands contain substances called additives.

Common additives include:

Buffers (e.g., magnesium carbonate, aluminum hydroxide) to decrease stomach upset.

Caffeine to act as a stimulant and lessen pain.

Antihistamines (e.g., diphenhydramine, pyrilamine) to help you relax or sleep.

Medicines with additives can cause some unwanted effects. For example, antihistamines sometimes cause drowsiness. This may be fine at bedtime, but it could be a problem during the day or while you are driving. Also, additives tend to increase the cost of nonprescription pain relievers. They can also change the action of other medicines you may be taking.

Plain aspirin, acetaminophen, or ibuprofen probably work as well as the same medicines with additives. But if you find that a brand with certain additives is a better pain reliever, ask your doctor, nurse, or pharmacist if the additives are safe for you. Talk with them about any concerns you may have about the drugs contained in your nonprescription pain medicines.

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NSAIDs

NSAIDs are similar to aspirin. Either alone or in combination with other medicines, NSAIDs are useful in controlling pain and inflammation.

PRECAUTIONS WHEN TAKING NSAIDs

Some people have conditions that may be made worse by NSAIDs or by any product that contains NSAIDs. In general, NSAIDs should be avoided by people who:

Are allergic to aspirin.

Are on chemotherapy (anticancer drugs).

Are on steroid medicines.

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

Are taking prescription medicines for arthritis.

Are taking oral medicine for diabetes or gout.

Have kidney problems.

Will have surgery within a week.

Are taking blood-thinning medicine.

Be careful about mixing NSAIDs with alcohol � taking NSAIDs and drinking alcohol can cause stomach upset and sometimes bleeding in the lining of the stomach.

"Hidden Aspirin"

Some opioid medications also contain aspirin. If your doctor does not want you to take aspirin, be sure to read the labels carefully. If you are not sure if a medicine contains aspirin, ask your pharmacist.

Side Effects of NSAIDs

The most common side effect from NSAIDs is stomach upset or indigestion, especially in older patients. Taking NSAIDs with food or milk or immediately following a meal lessens the chance of this occurring. Ask your pharmacist to tell you which NSAIDs products are less likely to upset your stomach.

NSAIDs also prevent platelets � blood cells that help blood clot after an injury � from working correctly. When platelets don't function as they should, bleeding is more difficult to stop.

NSAIDs can also irritate the stomach and cause bleeding. If your stools become darker than normal or if you notice unusual bruising � both signs of bleeding � tell your doctor or nurse. Other side effects include kidney problems and stomach ulcers.

ACETAMINOPHEN

This medicine relieves pain in a way similar to NSAIDs, but it does not reduce inflammation as well as NSAIDs. People rarely have any side effects from the usual dose of acetaminophen. However, liver and kidney damage may result from using large doses of this medicine every day for a long time or drinking alcohol with the usual dose. Moderate amounts of alcohol can produce liver damage in people taking acetaminophen.

Your doctor may not want you to take acetaminophen regularly if you are receiving chemotherapy. It can cover up a fever. The doctor needs to know about any fever because it may be a sign of infection, which needs to be treated.

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.

Table 2. 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 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.

Table 3. OTHER MEDICINES USED TO RELIEVE PAIN
DRUG CLASS	GENERIC NAME	ACTION	SIDE EFFECTS
Antidepressants	Amitriptyline Nortriptyline Desipramine	Used to treat tingling or burning pain from damaged nerves. Nerve injury can result from surgery, radiation therapy, or chemotherapy.	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	Help control nausea and help people sleep. Help control itching.	Drowsiness.
Anti-anxiety drugs	Diazepam Lorazepam	Used to treat muscle spasms that often go along with severe pain. Also lessen anxiety.	Drowsiness. May cause urinary incontinence.
Amphetamines	Caffeine Dextroamphetamine Methylphenidate	Increase the pain relieving action of opioids and reduce the drowsiness they cause.	Irritability. Rapid heartbeat. Decreased appetite.
Anticonvulsants	Carbamazepine Clonazepam Gabapentin Phenytoin	Help to control tingling or burning from nerve injury caused by the cancer or cancer therapy.	Liver problems and lowered number of red and white cells in the blood. Gabapentin may cause sedation and dizziness.
Steroids	Dexamethasone Prednisone	Help relieve bone pain, pain caused by spinal cord and brain tumors, and pain caused by inflammation. Increase appetite.	Fluid buildup in the body. Increased blood sugar. Stomach irritation. Rarely, confusion, altered behavior, and sleeplessness.