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.
FOR MILD TO MODERATE PAIN
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
a prescription for these medicines. Non-opioids may be used along
with opioids for moderate to severe pain.
FOR BREAKTHROUGH PAIN
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
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):
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
A prescription is needed for these medicines.
They are used to lessen swelling, which often causes pain.
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.
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.
injections — medicine is placed directly into the fluid
around the spinal cord (intrathecal) or into the space around
the spinal cord (epidural).
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.
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
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 control mild to moderate pain. Some
can be bought without a prescription. For detailed information on
nonopioids, review the chart below.
NON-OPIOIDS — ACETAMINOPHEN AND NSAIDs
||Reduces pain and fever.
Large doses can injure the liver or
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
|NSAIDs (Nonsteroidal Anti-Inflammatory
OVER THE COUNTER:
Choline Magnesium Trisalicylate
|Reduce pain, inflammation, and
NSAID medicines can have the following
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
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
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
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.
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
Are on chemotherapy
Are on steroid
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
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.
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
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
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.
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
|Combination Opioid/NSAID preparations
Codeine (with aspirin or acetaminophen)
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
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
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.
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
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.
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
Medicines that relieve nausea can sometimes
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
|Table 3. OTHER MEDICINES USED TO RELIEVE PAIN
||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.
||Help control nausea and help people sleep.
Help control itching.
|Used to treat muscle spasms that often go
along with severe pain. Also lessen anxiety.
||Drowsiness. May cause urinary incontinence.
||Caffeine Dextroamphetamine Methylphenidate
||Increase the pain relieving action of opioids
and reduce the drowsiness they cause.
||Irritability. Rapid heartbeat. Decreased
||Carbamazepine Clonazepam Gabapentin
|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
||Help relieve bone pain, pain caused by spinal
cord and brain tumors, and pain caused by inflammation. Increase
||Fluid buildup in the body. Increased blood
sugar. Stomach irritation. Rarely, confusion, altered behavior,