Whether it is acute or chronic pain from cancer or procedures, adequate management of pain medications is essential for any patient. Combination of different modalities of pain control or different classes of pain medications can be quite useful to patients.
Classes of pain medications
One of the oldest and best pain medications. Generally I will tell patients who don’t have liver issues to take this regularly at cumulative daily doses of less than 3000 mg a day. In patients without liver issues, chronic dosing is possible without common long term side effects.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
This will include medications such as ibuprofen, voltaren, naproxyn, and Vioxx. These medications are commonly underrated in how much pain relief they can provide. In patients without kidney problems, they are worth a trial of at least a few days. Note that chronic use beyond a few weeks can cause kidney problems and gastric ulcers.
In general the opioid compounds are considered stronger agents for pain control than NSAIDs or Tylenol. A major patient concern is addiction, which may occur more likely with short acting agents. An unfortunate choice may have to be made between the risk of addiction and adequate pain control – and most of the time we will pick adequate pain control. Other risks of opioids include respiratory depression and even comatose states from overdose and an increased risk of suicide. When first starting a new opioid pain medication it is important to start at low doses and titrate upwards (unless you are converting from another pain medication). It is also important to remember that combination pills which include Percocet, Vicodin, Darvocet, contain acetaminophen (Tylenol).
“Weak Opoids” include Tylenol #3, Vicodin, Darvocet. I list these agents as “weak” but for some patients they may actually work better than “strong” opioids.
“Strong Opioids” include Ultram, Fentanyl, Morphine, MS Contin, Dilaudid, oxycodone, Oxycontin, Percocet, Nucynta, Opana. Again, certain “strong” opioids such as Fentanyl are considered stronger than others (i.e. Oxycodone) but the effect of each pain medications varies with each patient.
“Long acting” agents include MS Contin or Oxycontin pills and the Fentanyl patch. These agents are used in chronic dosing such as twice daily (pills) or every 3 days (patch) and are very important for chronic pain control. They cause less of a “high” than the other agents which are short acting because they are slowly released into the bloodstream.
Fentanyl comes in a few different forms:
- Patch (the only long acting form)
- Lozenges (tastes super sweet)
- Actiq lollipops (tastes super sweet)
- Onsolis (a film you place on your cheek that is less sweet)
- Fentora (a tablet you place on your cheek)
- Lazanda (a nasal spray)
Neuropathic pain medications
Neuropathic pain, or pain in your nerves that is most common in the hands and feet, is a very irritating form of pain that can sometimes be caused by chemotherapy (i.e. Velcade or Taxol), but can also be caused by other factors such as diabetes or B12 deficiency. Patients describe it as a tingling, pins and needles, fire like pain, or numbness. A host of medications listed below are used to help patients with neuropathic pain. These medications sometimes need to be tried in trial and error fashion, and unfortunately, sometimes none of them work.
What we use for Neuropathic pain:
Other methods of pain control
- Celiac plexus block
- The celiac plexus is a nerve bundle that innervates the pancreas. In patients with pain from pancreatic cancer that does not respond to pain medication, a block to “burn off” the nerves of the celiac plexus may be attempted. Practically speaking, I have seen variable results from this procedure. Some patients get no relief and some get some relief from the pain. Part of the reason for some patients not getting relief may be the difficulty in getting a needle to the “right spot” in the celiac plexus to actually perform a nerve block (i.e. the needle may end up in the pancreas instead).
- Implantable PCA pumps